|Year : 2019 | Volume
| Issue : 2 | Page : 77-81
Using a nonablative monopolar radiofrequency laser in the treatment of acne vulgaris
Ju-Yeon Choi, Sang Hyeon Hwang, Junghwa Yang, Ga-Young Lee
Department of Dermatology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
|Date of Submission||01-Dec-2017|
|Date of Acceptance||19-Nov-2018|
|Date of Web Publication||23-May-2019|
Dr. Ga-Young Lee
29 Saemunan-Ro, Jongno-Gu, Seoul 03181
Source of Support: None, Conflict of Interest: None
Background: Acne vulgaris is a prevalent cutaneous disorder that significantly affects patient quality of life. There have been several reports of successful acne treatment using lasers. However, few studies have reported the use of radiofrequency (RF) lasers for acne. Objective: The purpose of this study was to evaluate the efficacy and safety of a noninvasive monopolar RF laser in the treatment of acne vulgaris on the face. Methods: A randomized, prospective, split-face study was performed. Eleven participants were recruited. Patients were treated with the RF laser on one half of the face and no laser treatment on the other half. Two treatments were performed at 2-week intervals. Patients returned for follow-up 2 weeks after the final treatment. Results: After 4 weeks, the lesion counts of papules, comedones, red macules, and the sebumeter measured values all significantly decreased on the treated area compared to those on untreated areas. In the photograph analysis, the grade of acne (using Cook's acne grading method) also significantly improved after treatment. Patients reported tolerable pain and mild erythema with laser treatment. However, there were no permanent adverse events. Conclusion: Treatment with the noninvasive RF laser successfully reduces acne lesions (papules, comedones, and red macules) and sebum secretion without severe adverse events.
Keywords: Acne vulgaris, noninvasive, radiofrequency
|How to cite this article:|
Choi JY, Hwang SH, Yang J, Lee GY. Using a nonablative monopolar radiofrequency laser in the treatment of acne vulgaris. Dermatol Sin 2019;37:77-81
|How to cite this URL:|
Choi JY, Hwang SH, Yang J, Lee GY. Using a nonablative monopolar radiofrequency laser in the treatment of acne vulgaris. Dermatol Sin [serial online] 2019 [cited 2019 Oct 17];37:77-81. Available from: http://www.dermsinica.org/text.asp?2019/37/2/77/258940
| Introduction|| |
Acne vulgaris is a common cutaneous disorder that involves the pilosebaceous unit. One survey, including 1013 participants aged 20 years and older, found that 73.3% of participants reported that they have acne. Although the peak prevalence of acne vulgaris occurs in adolescent patients, many patients suffer with acne vulgaris even in adulthood. Acne vulgaris affects patient quality of life much like other chronic disorders do. Patients with acne vulgaris are also at increased risk of anxiety and depression compared to those without, regardless of the severity. Diverse treatment methods have been recommended in the treatment of acne, including topical products (topical retinoids, benzoyl peroxide, and antibiotics), intralesional steroid injections, systemic antibiotics, contraceptives, isotretinoin, chemical peels, and various laser treatments., Treatment using the following types of lasers has been reported: pulsed dye laser, 532-nm potassium-titanyl-phosphate laser, 1450-nm laser, combined 585/1064-nm laser, 1550-nm Er: glass fractional laser, and nonablative radiofrequency (RF) laser.,,, The RF laser uses high-frequency (300 KHz to 30 MHz) alternating electrical current to create a thermal or nonthermal injury to the targeted area. There are rare reports of the use of RF devices in the treatment of active acne vulgaris. Therefore, we designed this study to evaluate the clinical efficacy and safety of the nonablative monopolar RF laser in the treatment of acne vulgaris.
| Methods|| |
This study was a single-centered, prospective, split-face, randomized controlled trial of the noninvasive monopolar RF laser treatment of acne vulgaris. This study was approved by the Institutional Review Board at Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine in Seoul, Korea. After informed consent was obtained from all participating participants, patients with acne vulgaris on the face were enrolled. Participants were excluded if they had keloid, connective tissue disorders, uncontrolled systemic diseases, had taken isotretinoin within 6 months, used topical acne preparations, or received chemical peels within 1 month of the study. No other acne-related treatments were performed during the follow-up. Only when the ingredients were identified, patients were allowed to use their existing emollients or cosmetics during the period. All of the patients were treated with a single pass of noninvasive monopolar RF laser (IntraGen®, Jeisys Medical Inc., Seoul, South Korea) on half of the face (right or left). The other half of each patient's face was not treated. The treatment areas were selected randomly. A 1.5 cm × 1.5 cm noninvasive grid fractional tip was used with 71 J/cm2 fluences and a frequency of 6 MHz. Cold gauze was applied to the face after the treatment for 5 min. Patients received two treatments at 2-week intervals. Patients then returned for a follow-up visit 2 weeks after the final treatments. Standardized digital photographs were taken before each treatment and at the follow-up visit using a handheld digital camera. The numbers of papules, pustules, comedones, cysts, and red macules were counted at each visit. The sebum secretions were measured at each visit using photometric assessment (Sebumeter® SM815, Courage and Khazaka Electronics, Cologne, Germany) on both cheeks. Two blinded investigators evaluated the photographs using an acne grading method suggested by Cook et al., as follows: Grade 0 – up to three small scattered comedones and/or small papules; Grade 2 – very few pustules or three dozen papules and/or comedones, lesions are hardly visible from 2.5 m away; Grade 4 – red lesions and inflammation to a significant degree; Grade 6 – loaded with comedones, numerous pustules, lesions easily recognized at 2.5 m away; and Grade 8 – conglobate, sinus or cystic type acne, or highly inflammatory acne covering most of the face, yellow pustules extend to neck and chin. Patient improvement was evaluated using a five-point global assessment scale (GAS), as follows: excellent – 75%–100% lesion clearance, score 5; good – 50%–74% lesion clearance, score 4; fair – 25%–49% lesion clearance, score 3; poor – <25% lesion clearance, score 2; and worse – results worse than the pretreatment findings, score 1. The adverse events and pain score were recorded at every visit. Repeated measures ANOVA was used to detect statistically significant changes in non-inflammatory, inflammatory acne lesion counts, sebumeter measured values, and acne grade according to time. The difference between the treated and untreated areas was analyzed using a paired sample t-test if the numbers followed a normal distribution. If not, the difference was analyzed using the Wilcoxon signed-rank test. P < 0.05 was considered statistically significant (SPSS 18.0, IBM Corp, Armonk, NY, USA).
| Results|| |
A total of 11 patients (6 males and 5 females) with facial acne vulgaris between 16 and 27 years old (mean age: 22.3) were included in the study. Nine patients had Fitzpatrick skin type Grade 3 and two had Grade 4. There was no significant difference in the acne lesion counts, sebum measured values, or acne grades between the two sides of the face before treatment.
The changes in the number of acne lesions (including papules, pustules, comedones, cysts, and red macules) with treatment are summarized in [Table 1] and [Figure 1]. There were statistically significant changes over time in the amount of papules, comedones, and red macules between the treated and untreated areas (P < 0.05). These three values were all significantly different between the treated and untreated areas at 4 weeks (P < 0.017).
|Table 1: Comparison of acne lesion counts, sebumeter measured values, and acne grades between treated and untreated areas|
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|Figure 1: The mean number of papules, comedones, red macules, and the sebumeter measured values in treated and untreated areas. *P < 0.017 compared with untreated area|
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There were also significant differences in the sebumeter-measured values treated and untreated cheeks with time (P < 0.05). This difference was also significant at the third visit (P < 0.017) [Table 1] and [Figure 1].
The acne grades improved in all of the treated areas. There was significant improvement in the treated versus untreated areas according to time (P < 0.05) and significant difference between the two sides of the face (P < 0.017) [Table 1]. Six patients experienced improvement in the acne grade of untreated areas. However, when the improvement of acne grade (median [interquartile range], %) was compared to the treated area and the untreated area for these six patients, the treated area improved 66% (58–100) but the untreated area improved 33% (25–75) (P = 0.039). This result further assures that the monopolar RF laser improves acne lesions. Clinical photographs of two patients are shown in [Figure 2] and [Figure 3]. Patient assessments of improvement on the treated areas using the five-point GAS ranged from worse to good. The mean subjective improvement was poor to fair (GAS 2.7).
|Figure 2: A 27-year-old woman with acne vulgaris. (a and c) Before treatment; (b) after two treatments with the noninvasive radiofrequency laser; and (d) untreated area on the third visit|
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|Figure 3: A 20-year-old man with acne vulgaris. (a and c) Before treatment; (b) after two treatments with the noninvasive radiofrequency laser; and (d) untreated area on the third visit|
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There were no significant adverse events such as facial burn, hyper- or hypo-pigmentation, or scar formation. Two patients experienced tolerable pain due to a feeling of heat which subsided once the laser treatment was complete. Two patients also reported mild erythema, which was self-limited after 1–2 days.
| Discussion|| |
Acne vulgaris is conventionally treated with topical agents (retinoids, antibiotics, and benzoyl peroxide), oral antibiotics, isotretinoin, steroid intralesional injections, and chemical peels. Various lasers and light-based instruments have been developed and gradually accepted as alternative treatments for acne vulgaris. A noninvasive RF laser is typically used for rejuvenation in areas of skin tightening. There is only one report on the use of a nonablative RF laser in the treatment of acne vulgaris.
Ruiz-Esparza et al. reported an excellent response in 82% of moderate-to-severe cystic acne vulgaris patients after 1–2 treatment sessions using an RF laser. The group suggested that heat inhibits sebaceous gland activity, decreases sebaceous gland volume, and stimulates remodeling of the dermal architecture. In our study, sebum secretion decreased on the treated area following two treatments. There was a statistically significant decrease in the sebum secretion of treated areas compared to that in untreated areas. This finding supports the hypothesis that heat energy reduces sebaceous gland activity. Ruiz-Esparza et al. used a nonablative unipolar RF device (ThermaCool TC®, Thermage Inc., Hayward, CA, USA). The estimated penetration depth of this device is half of the electrode size, which may allow the energy to reach the muscle layer. In our study, a monopolar RF laser with noninvasive grid fractional tip was used. The estimated penetration depth of this laser is the papillary and reticular dermal layer. Despite this superficial energy penetration, sebum secretion was still effectively reduced in treated skin.
Sadick et al. found that there was thermal damage to the hair follicles with vacuolar degeneration after the treatment with combined intense pulse light/RF laser treatment. This group suggested that light is absorbed by melanin in the hair shaft and that RF directly heats the hair follicle. The consistent temperature profile that is formed across the hair structure by combined treatment may damage the hair follicle. It is difficult to estimate the proportion of the hair follicles that would be damaged by RF energy. Regardless, the RF laser may induce follicular degeneration and reduce follicular hyperkeratinization.
Based on their study of pulsed dye lasers, one group suggested that coherent yellow light has a phototoxic effect on porphyrins in Propionibacterium acnes in the treatment of acne. Factors affecting P. acnes photoinactivation include porphyrin concentration, photon concentration, photon emission wavelength, and temperature. RF laser treatment increases the facial temperature, which may cause P. acnes inactivation. Exposure to the noninvasive RF laser increased the facial temperature by approximately 4.6°C–7.5°C. The maximum facial temperature was 40.4°C, according to a study conducted by the manufacturer. According to Lyte et al., the viability of P. acnes at room temperature, at 50°C (heat-treated), and at 70°C (heat-treated) was 74%, 31%, and 3.37%, respectively. Although the viability decreases with increased temperature, heat-killed P. acnes induces significant inflammatory responses that are similar to those of viable P. acnes (involving nitric oxide and interleukin-8). Therefore, the heat energy produced by the RF laser is not sufficient to reduce the viability of P. acnes or decrease inflammatory reactions. In other words, the main treatment strategy was not to destroy P. acnes.
Cho and Kim reported significant increases in the expression of tumor necrosis factor-α, transforming growth factor (TGF)-β, metalloproteinase (MMP)-1, MMP-3, MMP-9, MMP-13, heat shock protein (HSP) 47, and HSP 72 after the treatment with a noninvasive monopolar, grid fractional RF device. TGF-β can function as an anti-inflammatory cytokine and may reduce the inflammation present with acne vulgaris.
According to the above-mentioned mechanisms, the RF laser reduces the number of acne lesions (including papules, comedones, and red macules) and reduces sebum secretion. However, the treatments did not significantly reduce pustule and cyst counts. Most patients had few cysts (none or one cyst) and scanty pustules. The low prevalence of these lesions may have made it more difficult to detect significant treatment effects of the RF laser. Limitations of this study include a small number of patients and a relatively short follow-up period. Due to the short observation period, the duration of the treatment effect and the recurrence could not be confirmed. This period was also insufficient for the evaluation of acne scar. However, we could expect a relatively rapid effect on active acne lesions with only a few number of monopolar RF treatments. Further investigation with more participants, longer follow-up, and ideal treatment parameter adjustment is needed to substantiate these results and evaluate the effect of the laser on pustules and cystic acne lesions. It will be also interesting to examine the effects of acne on other types of monopolar RF devices and bipolar RF devices.
| Conclusion|| |
Treatment with the noninvasive RF laser reduces the number of acne lesions (papules, comedones, and red macules) and decreases sebum secretion without any severe adverse reactions. Therefore, nonablative monopolar RF laser could be an effective and safe alternative in the treatment of acne vulgaris.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
This work was supported by the Samsung Biomedical Research Institute (SBRI) grant.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Collier CN, Harper JC, Cafardi JA, Cantrell WC, Wang W, Foster KW, et al.
The prevalence of acne in adults 20 years and older. J Am Acad Dermatol 2008;58:56-9.
White GM. Recent findings in the epidemiologic evidence, classification, and subtypes of acne vulgaris. J Am Acad Dermatol 1998;39:S34-7.
Mallon E, Newton JN, Klassen A, Stewart-Brown SL, Ryan TJ, Finlay AY, et al.
The quality of life in acne: A comparison with general medical conditions using generic questionnaires. Br J Dermatol 1999;140:672-6.
Yazici K, Baz K, Yazici AE, Köktürk A, Tot S, Demirseren D, et al.
Disease-specific quality of life is associated with anxiety and depression in patients with acne. J Eur Acad Dermatol Venereol 2004;18:435-9.
Roman CJ, Cifu AS, Stein SL. Management of acne vulgaris. JAMA 2016;316:1402-3.
Taub AF. Procedural treatments for acne vulgaris. Dermatol Surg 2007;33:1005-26.
Jung JY, Choi YS, Yoon MY, Min SU, Suh DH. Comparison of a pulsed dye laser and a combined 585/1,064-nm laser in the treatment of acne vulgaris. Dermatol Surg 2009;35:1181-7.
Liu Y, Zeng W, Hu D, Jha S, Ge Q, Geng S, et al.
The long-term effect of 1550 nm erbium: Glass fractional laser in acne vulgaris. Lasers Med Sci 2016;31:453-7.
Ruiz-Esparza J, Gomez JB. Nonablative radiofrequency for active acne vulgaris: The use of deep dermal heat in the treatment of moderate to severe active acne vulgaris (thermotherapy): A report of 22 patients. Dermatol Surg 2003;29:333-9.
Cho SB, Kim HS. High-frequency alternating electrical current: Selective electromagnetic tissue reaction. Med Laser 2016;5:1-6.
Cook CH, Centner RL, Michaels SE. An acne grading method using photographic standards. Arch Dermatol 1979;115:571-5.
Sadick NS, Makino Y. Selective electro-thermolysis in aesthetic medicine: A review. Lasers Surg Med 2004;34:91-7.
Sadick NS, Shaoul J. Hair removal using a combination of conducted radiofrequency and optical energies – An 18-month follow-up. J Cosmet Laser Ther 2004;6:21-6.
Elman M, Lebzelter J. Light therapy in the treatment of acne vulgaris. Dermatol Surg 2004;30:139-46.
Lyte P, Sur R, Nigam A, Southall MD. Heat-killed propionibacterium acnes is capable of inducing inflammatory responses in skin. Exp Dermatol 2009;18:1070-2.
[Figure 1], [Figure 2], [Figure 3]