New photographic techniques for clinical evaluation of acne

Clinical evaluation of acne is usually based on direct visual assessment and ordinary flash photography, both of which are compromised by viewer subjectivity. It is difficult to accurately assess individual acne lesions and to observe early response to therapy. Standard flash photography has inherent limitations owing to the physics of light; it does not permit consistent visualization of subtle cutaneous characteristics like erythema or microcomedones, and it tends to blur distinctions between active inflammatory lesions and older hyperpigmented macules. Over the last decade there has been increasing interest in newer techniques aimed at increasing the accuracy and objectivity of acne evaluation. These include parallel‐polarized light photography, cross (or perpendicular)‐polarized light photography, videomicroscopy, and fluorescence photography. This article will review the advances of the past decade and summarize new techniques to evaluate acne lesions. Moreover, findings of a study that evaluated the course of individual acne lesions and the effects of adapalene gel 0.1% on inflammatory and non‐inflammatory acne lesions will be viewed. In this study, the use of parallel‐polarized and cross‐polarized photography, in combination with videomicroscopy and sebum production measurement, provided objective, detailed information on the evolution of different variable acne lesions and their response to adapalene gel 0.1%. Adapalene treatment produced rapid resolution of inflammatory and non‐inflammatory lesions, and inhibited formation of new lesions. Sebum secretion rates also declined during treatment. Use of the new assessment techniques proved to be a valuable, non‐invasive and reliable method of assessing acne vulgaris and its response to treatment.     

Development and evaluation of a Global Acne Severity Scale (GEA Scale) suitable for France and Europe

Background and objective Many acne grading methods exist; however, there is no agreed‐upon standard. Our objective was to create and validate a reproducible acne assessment scale for rating the severity of juvenile facial acne suitable for use in France and Europe. Methods The scale we created described the different types of acne lesions in a manner similar to global assessment scales used in clinical trials. The scale was then validated by seven expert dermatologists in the field of acne [the Global Evaluation Acne (GEA) group] first on 34 photographic cases of Caucasian acne patients and second by clinical examination of 22 acne patients. Results There was good agreement in Investigators’ assessments of acne both on photographs and patients (R = 0.8057; P < 0.0001, and R = 0.8437; P = 0.0015). Conclusion The GEA Scale is a global scale validated both on photographs and acne patients which can be used either in clinical research or by the dermatologist in his office.     

Treatment of mild-to-moderate acne vulgaris using a combined light and heat energy device: Home-use clinical study

Abstract

Introduction: Light and heat devices have become widely used for the treatment of mild-to-moderate inflammatory acne as an alternative to retinoids and antibiotics. The purpose of this study was to examine whether a hand-held device that emits both light and heat energy can safely and effectively be applied at home to shorten the time to improvement and time to resolution of acne papules and pustules. Methods: A two-center, randomized, placebo-controlled, double-blind study was conducted on 63 subjects with at least four inflamed, facial, acne lesions. Treatments were self-administered twice a day for 4 days. All lesions were photographed on a daily basis. Treatment results were assessed by two blinded evaluators, based on the macro photographs, using a 4-point visual analogue scale (VAS) and a photographic lesion reference scale (PLRS), as well as by the subjects. Safety was assessed based on evaluators and subjects’ reported side effects and adverse events. Results: Twenty-nine subjects in the treatment arm and 32 subjects in the placebo arm, with skin types II–VI, successfully completed the study. Based on blinded VAS scores, 92.24% of the lesions treated with an active device improved within a median time of 1 day versus 75.78% and a median time of 2 days for the placebo arm. At 24 hours the improvement rate was 76.72% for the active arm versus 15.63% for the placebo arm. Based on blinded PLRS scores, 87.07% of the lesions treated with an active device improved within a median time of 2 days versus 64.8% and 3 days for the placebo. A total of 51.7% of the active arm lesions resolved within a median time of 4 days versus 36% (no median) for the placebo arm lesions. No device-related adverse events occurred throughout the study. Conclusion: This study demonstrates the safety and effectiveness of the hand-held, combined light and heat energy device for at-home treatment of individual mild-to-moderate inflammatory acne lesions. Statistically significant shorter lesion improvement and lesion resolution rates were found.     

Erythema‐directed digital photography for the enhanced evaluation of topical treatments for acne vulgaris

Background

Erythema‐directed digital photography is a novel method for evaluating the efficacy and tolerability of topical acne treatments. Here, we describe three case reports in which erythema‐directed digital photography was used to evaluate acne before and after up to 12 weeks of treatment with clindamycin 1%/tretinoin 0.025% (Clin‐RA).

Materials and methods

Erythema‐directed digital photography was used to evaluate acne in three patients with mild‐to‐moderate facial acne, two of whom had refused to continue previous topical acne treatment (benzoyl peroxide 5% and clindamycin 1%/benzoyl peroxide 5%) due to persistent irritation. Acne lesions and erythema were evaluated using standard clinical photography and erythema‐directed digital photography (VISIA‐CR^™ system) before and after 8‐12 weeks of treatment with Clin‐RA.

Results

Erythema‐directed digital photography revealed background erythema from previous topical acne treatments that was not evident from standard clinical photographs and allowed a better visualization of both inflammatory and non‐inflammatory lesions. In all patients, there was a clear improvement in background erythema and a reduction in acne lesions following treatment with Clin‐RA.

Conclusion

This study has demonstrated for the first time that erythema‐directed digital photography can enhance the evaluation of the efficacy and tolerability of topical acne treatments. These cases show that Clin‐RA was associated with improved efficacy and tolerability vs previous treatments with topical monotherapy (benzoyl peroxide 5%) or a topical fixed‐dose combination (clindamycin 1%/benzoyl peroxide 5%).

     

An assessment of the efficacy of blue light phototherapy in the treatment of acne vulgaris

Background Acne vulgaris is a common skin condition that affects 8 out of 10 people. It varies from mild to severe, and different treatments target various aspects of the disease. Propionibacterium acnes, one of the culprits involved in the pathogenesis of acne vulgaris, is the main target of all major medical treatments used. Studies conducted in recent years have shown favorable effects within the visible light spectrum for the treatment of acne vulgaris. Objective In this study, we have evaluated the use of intense blue light within the spectral range of 415–425 nm (peak 420 nm) in the treatment of acne vulgaris. Methods Twenty‐one patients with mild to moderate facial acne were treated with blue light phototherapy. All patients were given 14‐min treatment sessions twice a week for 4 weeks. Acne severity was assessed using the Leeds Technique for grading and lesion counts. Disability was assessed using the Dermatology Life Quality Index (DLQI). In addition, standard digital and cross‐polarized light photographs were taken and graded by a blinded evaluator. Visual analog scale (VAS) scores and cultures for P. acnes were carried out before starting the treatment and upon completion of the treatment. Results Significant improvement was achieved in the Leeds Acne Grade (P = 0.001). The inflammatory (P = 0.001) and noninflammatory (P = 0.06) lesion counts also improved significantly. A similar change was noted in the DLQI (P = 0.001); a degree of significance was also achieved in the patients’ and the investigators’ VAS scores (P = 0.01 and P = 0.001, respectively). P. acnes colony counts failed to show a significant decrease at the end of the treatment and remained almost constant (P = 0.660). Conclusions We believe that blue light does appear to have some role in the management of acne and may be beneficial for the treatment of a select group of mild to moderate acne patients.     

The effective treatment of acne vulgaris by a high‐intensity,narrow band 405–420 nm light source

BACKGROUND: Available topical treatments are slow and frequently irritating. Oral therapies may be associated with increased bacterial resistance (antibiotics) or possible severe side effects (oral isotretinoin). In vitro and in vivo exposure of acne bacteria to 405–420?nm ultraviolet (UV) free blue light results in the photo‐destruction of these bacteria through the effects on the porphyrins produced naturally by Propionibacterium acnes. A novel, high‐intensity, narrow band 420?nm UV free blue light has been shown to decrease inflammatory acne lesions after eight bi‐weekly treatments.

OBJECTIVES: To examine the effects of high‐intensity, narrow band 420?nm UV free blue light (ClearLight^?) on inflammatory acne lesions.

METHODS: Three studies were carried out to examine the clinical effects of high‐intensity, narrow band blue light on papulo‐pustular acne: the split‐face dose–response study, the full‐face open trial and the split‐face, double‐blind controlled study. The studies enrolled 10, 13 and 23 patients respectively.

RESULTS: The data show more than an 80% response to 420?nm acne phototherapy with a significant reduction of 59–67% of inflammatory acne lesions after only eight treatments of 8–15 minutes. The reduction in lesions was steady in the follow‐ups at 2, 4 and 8 weeks after the end of therapy. Prolonged remission was evident in the 8 weeks after the end of therapy. No adverse effects or patient discomfort were noted in any of the patients.

CONCLUSIONS: Acne phototherapy by high intensity, narrow band 405–420?nm light is proven to be an attractive, fast, effective, non‐invasive alternative to current topical and parenteral anti‐acne remedies.     

Use of a TriPollar radio-frequency device for the treatment of acne vulgaris

Abstract

Introduction: Acne vulgaris is a common disease affecting mainly teenagers and young adults. Current treatment modalities include local or systemic medications, which often require a long intake. Light and radio-frequency (RF) devices have recently been used to treat acne in selected patients. Objective: To evaluate the safety and efficacy of TriPollar RF technology for non-invasive treatment of acne vulgaris lesions. Methods: Twenty patients with active acne lesions underwent TriPollar RF treatments once a week for 6 weeks. Results were evaluated using photographs and active lesion counts at baseline, before subsequent treatment sessions and at follow-up visits. Patients also rated their satisfaction on a 5-score rating scale. Results: An average reduction of 42% in active acne lesions was found after six TriPollar sessions, which was sustained at the 4-week follow-up visit. The average improvement rated by patients at the 4-week follow-up visit was 2.5, indicating good to very good satisfaction with the clinical results. No significant adverse events were recorded during the study and follow-up period. Conclusion: The findings confirm the safety and efficacy of TriPollar RF for the treatment of acne vulgaris.     

The clinical features of late onset acne compared with early onset acne in women

Background Little is known about the clinical characteristics of acne based on the age of onset. Objectives The aim of this study was to investigate the clinical characteristics of patients according to the age of onset of acne and evaluate whether the findings were related to regional differences in the density of Propionibacterium acnes or the levels of sebum secretion. Methods A total of 89 women were recruited. The acne lesions were assessed by counting the lesions using standard digital photographs. Digital fluorescent photography for the evaluation of the density of P. acnes were taken and quantitative measurements of facial sebum secretion were performed. Results In women with acne, the age of onset was negatively correlated with the number of comedones and the proportion of comedones. By comparing the number of comedones and the proportion of comedones, onset of acne after 21 years of age was defined as late onset acne. In the patients with late onset acne, the number of comedones, the total number of acne lesions and the proportions of comedones were significantly less than in the patients with early onset acne. However, there were no significant differences in the fluorescence density of P. acnes or the level of sebum secretion between the two groups. Conclusions The results of this study, using objective evaluation tools, suggest that late onset acne has different clinical characteristics. Other possible factors might explain the clinical differences in late onset acne.     

The role of pulsed light and heat energy (LHETM) in acne clearance

BACKGROUND: Propionibacterium acnes synthesize and store a large amount of porphyrins. Once the porphyrin is exposed to visible light it becomes chemically active and transfers to an excited state, resulting in the formation of singlet oxygen, which combines with cell membranes to destroy the P. acnes. This process is dependent on the rate of production of excited porphyrin molecules, which is influenced by the concentration of porphyrins, the concentration of photons, the temperature, and the wavelength of the photons.

METHODS: Nineteen patients with mild to moderate acne underwent bi‐weekly treatments for 4 weeks using the ClearTouch^TM system. During each treatment, pulses of light and heat were applied. Each pulse used an average energy density of 3.5?J/cm², a pulse width of 35?ms, and a wavelength between 430 and 1100?nm.

RESULTS: At the end of the eighth treatment, acne clearance for the non‐inflammatory and inflammatory lesions was 63±21% and 50±32%, respectively. One month after the last treatment, the acne clearance for non‐inflammatory and inflammatory lesions was 79±22% and 74±20%, respectively, with further improvement in acne clearance at 2 months after the last treatment (85±17% and 87±25%, respectively).

CONCLUSION: ClearTouch pulsed light and heat energy (LHE^TM) technology is effective and safe for the treatment of acne vulgaris.     

A quantitative assessment of the human skin surface using polarized light digital photography and its dermatologic significance

Background: Quantitative and objective investigations of parallel‐polarized light (PPL) photography for dermatologic purposes are scarce. Objective: To determine the significance of quantitative analysis of PPL photography to develop objective measurement methods of skin surface characteristics. Method: For PPL photography, a digital camera, a light‐emitting diode illuminator, and polarizing filters were arranged and kept constant. We analyzed the PPL photography images of the glabella, the medial aspect of the forearm, and the posterior aspect of the lower leg, and measured the CIELAB values. A dermatologist evaluated the clinical severity of the actual photographed sites with respect to glossiness and dryness. These clinical severities were compared statistically with the CIELAB values. Results: According to the correlation analysis, the L^* value was negatively correlated with dryness (r=?0.29869, P=0.0047) and glossiness (r=?0.35367, P=0.0185). Conclusion: The method used in this study is applicable to the quantitative evaluations of other dermatologic diseases or conditions, especially in relation to skin surface changes.     

Fluorescence diagnostic imaging in patients with acne

Background: Orange‐red fluorescence in the follicle openings, induced by ultraviolet A light, originates from porphyrins, the metabolic products of Propionibacteria acnes. Purpose: To investigate the relationship of orange‐red follicular fluorescence with the severity of acne and the amount of sebum secretion. Methods: Twenty‐five volunteers were included. The severity of acne was rated on a 4‐point scale. The casual sebum level was measured using a Sebumeter and the follicular fluorescence was determined using the camera Visiopor. Results: Casual sebum level and the intensity of fluorescence (percentage of the area and number of orange‐red spots) were higher at the T zone than at the U zone in all patients regardless of their skin type. Sebum amount and area of fluorescence spots were significantly negative in correlation with the clinical grade of acne. There was a significant positive correlation between the orange‐red fluorescence and the casual sebum level. Conclusion: The orange‐red fluorescence showed stronger correlation with the presence of non‐inflammatory acne lesions (comedones) and high sebum amount than the presence of inflammatory acne lesions (pustules) and low sebum amount. The fluorescence diagnostic imaging could be useful in the objective evaluation and monitoring of treatment efficacy in subjects with acne‐prone skin and patients with acne.     

Combination blue (415 nm) and red (633 nm) LED phototherapy in the treatment of mild to severe acne vulgaris

Background and objective: Acne vulgaris represents both a challenge to the treating dermatologist and a major concern for the patient. Conventional treatments have proved inconsistent with often unacceptable side effects and high rates of recurrence. Non‐thermal, non‐laser, phototherapy for acne with a combination of blue and red light has recently attracted attention. The present study was designed to assess the efficacy of this combination phototherapy.

Methods: Twenty‐four subjects, Fitzpatrick skin types II–V, with mild to severe symmetric facial acne vulgaris were recruited for the study. Subjects were well matched at baseline in terms of both age and duration of acne. Subjects were treated over eight sessions, two per week 3 days apart, alternating between 415?nm blue light (20 minutes/session, 48?J/cm²) and 633?nm red light (20 minutes/session, 96?J/cm²) from a light‐emitting diode (LED)‐based therapy system. Patients received a mild microdermabrasion before each session. Acne was assessed at baseline and at weeks 2, 4, 8 and 12.

Results: Twenty‐two patients completed the trial. A mean reduction in lesion count was observed at all follow‐up points. At the 4‐week follow‐up, the mean lesion count reduction was significant at 46% (p = 0.001). At the 12‐week follow‐up, the mean lesion count reduction was also significant at 81% (p = 0.001). Patient and dermatologist assessments were similar. Severe acne showed a marginally better response than mild acne. Side effects were minimal and transitory. Comedones did not respond as well as inflammatory lesions.

Conclusions: Combination blue and red LED therapy appears to have excellent potential in the treatment of mild to severe acne. Treatment appears to be both pain‐ and side effect‐free.     

Significant reduction of inflammation and sebaceous glands size in acne vulgaris lesions after intense pulsed light treatment

Intense pulsed light (IPL) has been used for years in treatment of acne vulgaris. However, quantitative evaluation of histopathological changes after its use as a sole therapy was poorly investigated. Accordingly, this study aims to objectively evaluate inflammatory infiltrate and sebaceous glands in acne vulgaris after IPL. Twenty‐four patients of acne were treated with six IPL sessions. Clinical evaluation was done at 2 weeks after last session by counting acne lesions. Patient satisfaction using Cardiff Acne Disability Index (CADI) was recorded at baseline, 2 weeks and 3 months after IPL. Using histopathological and computerized morphometric analysis, quantitative evaluation of inflammatory infiltrate and measurement of surface area of sebaceous glands were performed for skin biopsies at baseline and 2 weeks after last session. After IPL, there was significant reduction of all acne lesions especially inflammatory variety with significant decrease of CADI score at 2 weeks and 3 months after IPL (p < .05). Microscopically, there was significant decrease in density of inflammatory infiltrate and surface area of sebaceous glands (p < .05). So, IPL is fairly effective therapy in acne vulgaris especially inflammatory variety. The results suggest that IPL could improve acne lesions through targeting both inflammation and sebaceous glands.     

Efficacy and safety of oral silymarin in comparison with oral doxycycline and their combination therapy in the treatment of acne vulgaris

Two factors of oxidative stress and inflammatory processes are implicated in pathogenesis of acne vulgaris. Silymarin has antioxidant and anti‐inflammatory activities. This study was done to evaluate the effect of oral silymarin in the treatment of acne vulgaris compared to doxycycline and also their combination therapy. This randomized controlled trial was performed on 60 patients with acne vulgaris were divided into three groups of 20 patients, including: Silymarin (Group 1), Doxycycline (Group 2), and both compounds (Group 3). The patients' response was monitored every month and the lesions were evaluated using photography and two methods of Global Acne Grading system (GAGS) and Acne Severity Index (ASI). According to the results, the response to silymarin was not significantly different with doxycycline in the GAGS index (p = .260), but was lower in the ASI (p = .021). In this study, the synergistic effects of silymarin and doxycycline combination have been investigated in comparison with doxycycline. Although the improvement was more favorable in combination group, there was no statistically significant difference (p = .9 in ASI and p = .5 in GAGS). The results of our study suggest that although the silymarin monotherapy is not as effective as doxycycline for the treatment of acne vulgaris, it can be a therapeutic option.     

Fluorescence digital photography of acne using a light-emitting diode illuminator

BACKGROUND/PURPOSE: The fluorescence findings of several dermatological diseases, such as erythrasma, tinea versicolor, and acne are helpful for diagnosis and follow-up. However, many experience difficulty taking photographic images of fluorescence. The aim of this study was to develop a 405 nm light-emitting diode (LED) system for fluorescence digital photography of acne and to determine whether such a diode can be used to evaluate acne. METHODS: Eight healthy acne patients were compared with controls by fluorescence digital photography using a digital camera equipped with a 405 nm LED illuminator. Digital photographs were taken by two different ways of exposure, i.e. appropriate exposure level and longer exposure. One side of the nose, cheek, and glabella was compared. The numbers and extents of fluorescence dots were counted and measured. As normal controls, seven individuals with apparent oiliness and no acne were enrolled. RESULTS: Red fluorescent facial dots were observed and photographed digitally using the 405 nm LED illuminator. These were more numerous and extensive on the glabella and cheeks of acne patients. CONCLUSION: Fluorescence digital photography of acne was successfully performed using a 405 nm LED illuminator. This illuminator could be used for acne evaluations.     

Comparison of pulsed dye laser versus combined pulsed dye laser and Nd:YAG laser in the treatment of inflammatory acne vulgaris

Background: Both pulsed dye laser and combined 585/1064-nm (sequential dual-wavelength PDL and Nd:YAG) laser improves inflammatory skin disorders including acne vulgaris. Objective: To compare the efficacy of 585-nm pulsed dye laser versus sequential dual-wavelength PDL and Nd:YAG in treatment of acne vulgaris. Patients and method: Thirty patients with acne vulgaris were treated by PDL alone on half of the face while contra lateral half was treated by combined 585/1064 nm laser. Results: The study showed that inflammatory acne lesions count was significantly reduced by 82.5% (p 0.0001) on PDL sides and by 83.5% (p 0.00001) on combined 585/1064-nm side after 8 weeks, while reduction of non-inflammatory acne lesions was observed at 8 weeks by 58.4% and 71.5% respectively. However, difference between the two modalities was not statistically significant. Conclusion: PDL and combined PDL/Nd:YAG laser treatment were found to be an effective, safe and well-tolerated treatment option for inflammatory and non-inflammatory acne vulgaris.     

A comparative split-face study of photodynamic therapy with indocyanine green and indole-3-acetic acid for the treatment of acne vulgaris

Background Recently, photodynamic therapy (PDT) using a variety of light sources and photosensitizers has been used for the treatment of acne vulgaris. PDT with aminolaevulinic or methylaminolaevulinic acid has also been used in clinical trials as a treatment for acne, but adverse effects such as pain, erythema and pustular eruption are common. Indocyanine green (ICG) and indole‐3‐acetic acid (IAA), newer photosensitizers, are known to have minimal adverse effects. Objectives This study was designed to compare the safety and efficacy of PDT using ICG and PDT using IAA in the treatment of mild to moderate acne vulgaris. Methods In this prospective, single‐blind, clinical trial, 34 patients with mild to moderate acne were treated with IAA with green light (520 nm) on half of the face and with ICG with near‐infrared radiation (805 nm) on the other half. The procedure was carried out five times at 1‐week intervals. Results With regard to acne lesions (inflammatory and noninflammatory) and sebum secretion, there were statistically significant reductions at each time point compared with the baseline values (P < 0·05). However, there were no statistically significant differences between the two treatment types (P > 0·05). Both ICG‐PDT and IAA‐PDT showed better responses for inflammatory lesions than for noninflammatory lesions (P < 0·05). Subjective satisfaction score were statistically significant at 4 and 5 weeks of treatment as well as at 1, 2 and 3 months follow‐up (P < 0·05). Conclusions Both PDT with ICG and PDT with IAA are safe and effective for the treatment of mild to moderate acne vulgaris.     

Light‐emitting diode 415 nm in the treatment of inflammatory acne: An open‐label,multicentric, pilot investigation

Background. The management of acne remains a challenge, with current therapies linked to significant side effects and patient non‐compliance. Phototherapy using blue light has been proven in the treatment of acne vulgaris and offers the clinician an effective alternative.

Objective. To determine the effect of narrowband light‐emitting diode (LED) blue light in the reduction of inflammatory and non‐inflammatory lesions in patients with mild to moderate acne and to evaluate patient tolerance of the therapy.

Methods. Forty‐five patients were treated with high‐intensity pure blue light, 415?nm and 48?J/cm², receiving two treatments of 20?minutes per week for a period of 4–8 weeks. Clinical assessment was performed at baseline, and 2, 4 and 8 weeks after treatment. A patient's therapeutic response was measured using a global improvement scoring system.

Results. The mean improvement score was 3.14 at 4 weeks and 2.90 at 8 weeks. Nine patients experienced complete clearing at 8 weeks. The treatment was well tolerated, with 50% of patients highly satisfied with the treatment.

Conclusion. This open‐label study suggests the therapeutic efficacy of high‐intensity LED pure blue light in the treatment of acne vulgaris with no reported side effects.     

Facial sebum affects the development of acne,especially the distribution of inflammatory acne

Background The increased sebum secretion has been considered as one of the pathogenic factors of acne. Objective The goal of this study was to assess the correlation between the casual sebum level and the severity of acne using objective measuring methods in a large acne patients group. We also investigated the influence of age or gender on the correlation. Methods A total number of 914 acne patients were recruited. The standard digital photographs were taken, and the acne lesions were counted as comedones or inflammatory lesions. The casual sebum level was measured using the Sebumeter SM 815^®. The correlation analysis was performed. Results The casual sebum level showed positive correlation with the number of acne lesions. The casual sebum level markedly influenced the number of inflammatory lesions and the acne lesions located in the U‐zone. In the young acne patients, the casual sebum level showed significant correlations in the U‐zone, whereas in the old acne patients, there were significant correlations in the T‐zone. The male acne patients were more influenced by the casual sebum level. Conclusion This was the first study to report the significant correlations between the casual sebum level and the number, proportion and location of acne lesions in a large acne patients group, using an objective, bioengineering method. Moreover, we also found that the influence of sebum was prominent on the inflammatory lesions. In addition, both age and gender influenced the correlation between the casual sebum level and the acne.