Dr Stephen Eubanks explores using low-level light to trigger a biologic response and effectively treat acne and rosacea
There are many ways to treat acne and rosacea and several different classes of light and laser treatments, all designed to damage or treat the sebaceous glands—offering different ways of shrinking them.
Treatments include blue light and Levulan, 810 nm diode lasers, the use of 1450 nm Smoothbeam, 405 nm light with IPL blue light and also red light phototherapy. There are also high power lasers—either 595, 755 or 1064 nm, used primarily to treat the vascular component. All of these lasers work by using the theory of selective photothermolysis. This theory combines a wavelength of laser that is attracted to a vascular target combined with a pulse that keeps the heat within the target. These concepts are used to damage or destroys a vascular target. However, these are often not ideal because they are either painful, or not effective. Several other excellent approaches to treatment of these conditions exist, but let’s look specifically at the other options that use light and laser.
One of these approaches is bio stimulation—using some low-level laser light to trigger a biologic response—an approach that many people don’t believe in, but that I use to successfully treat both acne and rosacea.
An example of low-level light is to point a flashlight at your hand. The light penetrates all through your hand, allowing you to actually see the bones in your hand. Low energy light that has a high number of photons, can penetrate the hand. You can use that low-level laser light to gently heat a target—it doesn’t need high energy. In fact if you expose tissue to high energy this doesn’t happen, but if you expose it to low energy photons you can get bio stimulation.
Laser doctors say there’s no way this is going to work, that my laser doesn’t penetrate deep enough—only a millimetre—and that these low level laser light can’t work, but in my mind there are two different approaches: low energy bio stimulation and high-energy destruction.
This is a paradigm change in how I can approach work with lasers. I use a product called Regenlite Transform—a 585 nm pulse dye laser with a very short pulse of 350 microseconds. Unlike the original 450 microsecond Candela lasers that caused bruising, or what we call purpura, this new system can deliver multiple stacked pulses. These are very low energy for each one, so you can get a cumulative amount of energy that never exceeds a purpuric threshold.
The 585 nanometre light, was the original light used in all pulse dye lasers, but not every company could use this because they couldn’t stabilise this wavelength. However, this wavelength is infinitely more absorbed by haemoglobin than 595 nm laser light. You can use lower fluences to get these same results.
The Regenlite can deliver two different types of pulses. One is a standard vascular treatment for treating blood vessels. We can still stack these pulses, so we have fewer problems with purpura, but most of the time when we’re treating vascular lesions at this higher type of pulse the purpura is unavoidable. A year ago I would never have done this because it would have caused too much purpura, but now with the stacking of pulses with the newest model you can treat the red vascular component of rosacea without causing purpura. Using biostimulation and using your body’s immune response to attack rosacea is much, much more effective.
The second pulse profile that Regenlite has is what they call a SmartPulse. The laser pulse comes out at high energy first, then tapers off —whereas the other methods are slow to rise and then drop off. The 585 nm laser light is still absorbed by blood vessels but it doesn’t have enough energy to destroy them. It heats them up which triggers an injury response. The damage stimulates the body to give a bio-stimulatory response. I use this SmartPulse in all my acne and rosacea patients. It’s a totally different approach to what I’ve done in the past.
I believe, despite the fact that most laser physicians today do not believe in low level laser light, that five years from now it will be equally as important as high energy laser light.
Rosacea is complicated and I still don’t think we completely understand all the mechanism or actions of what really causes it. The many triggers include sunshine and we see that almost everything patients do in regular life all make rosacea worse.
Remember that a trigger causes an immunologic response. Even if rosacea and acne are two different diseases, when you go beyond the clinical their immunologic responses what the body is doing are very similar.
With acne or rosacea there are three steps of the treatment and the disease. First you can try to treat the bacteria. There can be bacteria in rosacea, but there’s more in acne. When treating Propionibacterium acnes you are trying to reduce the Propionibacterium, which lives primarily on fatty acids in sebum secreted by sebaceous glands in the follicles. Lasers can be used and light treatment, such as blue light where singlet oxygen damages the bacteria. However, low-level light has been shown not to affect P. acnes.
The next thing to treat is the damage that rosacea and acne both cause. There can be physical damage, to either the hair follicle spaces, or the overlying epidermis and you have to find a way to fix that. Something with wound healing properties makes both these conditions better.
Finally there’s an anti inflammatory approach to treating both acne and rosacea. Regenlite can fix all three of these parts of the condition, however evidence shows it does not reduce the number of P acnes. Importantly, this reveals either that by itself the bacteria is not the primary culprit in either acne or rosacea, or that it doesn’t have to be removed.
With this low level 585 nm light, you dramatically increase the level of transforming growth factor beta. (TGF-β) TGF-β is one of what they call a super family of growth factors. It does many different things. It can control cell proliferation, it can control cell differentiation and it can control inflammation.
This factor is also associated with cancer because cancer cells have the ability to disrupt the effect of TGF-β. But as far as we’re concerned TGF-β is involved with neo-cologenesis, which means it makes new collagen and with immuno-suppression. Many articles have been published that show how TGF beta makes new collagen.
Regenlite originally was created to treat wrinkles, now we know it builds new collagen. The repair of making new collagen is what we use to fix follicular structures that have been damaged either by acne or rosacea. So think of wrinkle repair and acne repair, it’s very similar because new collagen helps build new structures.
The most important and interesting part of this is the inflammatory effect of TGF-β. Patients with acne or rosacea have a long list of what we call cytokines—small proteins responsible for cell signalling in the body. You have probably heard of tumor necrosis factor (TNF-α), an immune cell regulator that’s associated with psoriasis for instance. Enbrel and Humira injections are cytokines that affect TNF-α, and almost always they do bad things.
We’re looking at the inflammatory cytokines—so nuclear factor kappa B is one, TNF-α, IL-1, IL-10, IL-8 are all inflammatory cytokines. There is good evidence that TGF-β can reduce these cytokines within 48 hours of having a laser treatment. They reduce the inflammatory cytokines that are causing the inflammation from the rosacea or the acne.
Our latest finding is that TGF Beta also stimulates a class of T-lymphocytes called T-regulatory cells. T regulatory cells impart long-term anti-inflammatory properties to the skin—potentially a lifelong anti-inflammatory to the acne-causing cytokines. This is why when we treat patients, they often stay clear.
I have patients now who have been symptom free for two years. I do a series of four treatments two weeks apart. I have people who had horrible rosacea and nothing had worked for them. I have one patient whom I have given four treatments and 18 months later he’s still 100% clear. That we believe is because of the his T-regulatory response.
Can you get rid of redness? Absolutely. We treat redness still at the low level, at the stacking mode, but we also know that we’re giving a long-term anti-inflammatory response. Another patient with acne on her chin for 10 years also had diffuse redness and everything she tried did absolutely nothing. We gave her two treatments and she has not had an outbreak for two years. It’s amazing because something is happening immunologically.
Treatment for a full face takes three or four minutes and it’s painless, there’s zero down time. Hopefully this shows you that there are some alternatives and a new mechanism of action, a new approach to treating these diseases.
Dr Stephen Eubanks discusses treatment method for rhinophyma
Q: What would be the suggested pharmacological preparation of a patient for surgical treatment of rhinophyma?
A: Rhinophyma is a disease whereby you have a lot of oil production and you have textural irregularity. So my main focus is on changing texture and improving the texture, suppressing the disease, inactivating the disease before the procedure because if I do a procedure on active disease the disease is going to be worse afterwards because procedures activate oil glands.
In my practice I choose textural improving agents so I control oil. And we do things like beta-hydroxyl acid and azelaeic acid to do that. I use an exfoliating agent such as 10% lactic and glycolic acid to help with the texture and to improve the keratin turnover. And I use a 1% retinol product, the product I use in this circumstance is called Retin-A.
So I’m preparing the skin for at least six weeks beforehand. Then I would do the procedure such as the CO2 fractionated laser once a patient’s skin has healed fully. Afterwards I put them on the Accutane 20milligrams, to shrink the sebaceous glands permanently because after the procedure you get a reactivation of oil glands. So to prevent disease recurrence and the patient looking worse afterwards I introduce my Accutane then.
Q: How much further along the line with Accutane would you treat the patients. If you just treat them for a six month period with 20 mg, two years along the line sebaceous glands may start to produce oil so would you target it as a long term?
A: Accutane is a medication that’s been around for many, many years and the more that we learn about it the more we understand how to use it. To answer your question I do five months 20 milligrams once a day, so I do low dose Accutane, and at the end of that 50% improve and 50% don’t improve. So 50% have long term remission forever, and the other 50% don’t. Is that different to high dose? High dose you have the exact same failure rate, so high dose if I use it based on your weight and I give you 40 – 60 milligrams of Accutane a day still at the end of the five months you’re going to have 50% improve and 50% don’t improve. So that’s why I go with the low dose, because it has the same success failure rate.
That 50% who don’t improve, when are they going to show signs of rosacea again? I don’t know, it could be in five years time, it could be in 20 years time, I don’t know when they’re going to show the signs that it’s failed on them. If it happens to come back then I have a choice. I can either put them on a second dose of 20 milligrams once a day for five months and then 50% will improve and 50% won’t improve, or a lot of times in my practice if it starts to recur I do continuous micro doses of
Accutane. You can take ten milligrams once a day for the rest of your life, you can have 20 milligrams twice a week, three times a week, or you can pulse, you can do that for three months, take three months. Three months on, three months off. There are lots of different ways in the literature that you can play around with the drug.
Q: What about dangers of Accutane?
A: As dermatologists our role is to have a high index of suspicion and know the right questions to ask. So if somebody coming in is complaining of getting migraines, problems with nausea and seeing double vision, I have to know that there is a chance that you could have pseudo tumor cerebrii, which is a very rate thing that is associated with Accutane.
I must know about the side effects, the potential side effects, even if a lot of them are uncommon I must be able to know that when somebody comes in and complains of these things I know the right questions to ask. I know she needs to go to a neurologist, she needs to have a lumbar puncture, she needs to have an MRI.
You have to have a high index of suspicion, yes there are risk, yes you need to know about depression, but that’s not going to be an absolute contra indication for me to put somebody on the medication.
Dr Stephen Eubanks, is a dermatologist from Denver Colorado