One of the most gratifying things about medicine is to see the remarkable advances in treatment. Fortunately, severe cystic acne is one of these success stories. With the development of Accutane we are able to not ony able to control severe cystic acne but also to, for the first time cure it. This is not to say athe drug is without side effects. Indeepd the side effects can be serious and alarming. These include birth defects, pancreatitis, joint pain, neurologic problems, possible depression and a myriad of other problems. Thus, this drug should be given with care and after careful discussion and consideration.
There have also been advances in antibiotic treatment. I find Soladyn to be an excellent drug. By improving the delivery system of Minocycline, we are able to give this drug in much lower doses than before with a subsequent marked decrease in side effects. Doryx and Adoxa Doxycyclines) are also excellent drugs which have been reformulated to make it more tolerable.
The birth control pill Yaz is another advancement in treatment of cystic acne. When I first started treating acne, most birth control pills worsened the condition. We would seek out ones that did acne no harm and maybe improved acne a bit ( Ortho-Novum). Generally, the estrogen agent improves acne and the progestational agent (which is further down the chain heading toward testosterone) worsened it. What was developed with Yaz, is the use of Drospirenone. This is the progestational agent in their birth control pill. This is closer to spirinolactone and has anti-androgen characteristics. Since androgens flare acen, the use of drospirenone, has given us a new weapon in the fight against acen. I find it very useful to use Yaz in female patients in whom I am contemplating the use of Accutane. If Yaz calms their acne all to the good. If not, and th patient needs Accutane, they already have birth control coverage.
Sometimes, in appropriate patients one can use spirinolactone itself ( Never the twoo together since they both cause potassium retention). This blocks the male hormone both in the adrenal gland and at the end- site (the sebaceous or oil gland).
Then there is the use of lasers the CoolTouch (at 1320 nm.) or Smoothbeam (at 1450) or the Aramis (1540). All three of these lasers work by altering the sebaceous gland. They cause a change in the shape of the gland and the amount of sebum they release. Sometimes these lasers can be used in patients who are refractory to other treatments, even Accutane.
Other light devices such as the IPL blue light or IPL red light work by both changing the sebaceous glands and attacking the incriminating bacteria. These devices can be made even more effective with the use of photodynamic therapy, combining Levulan and Photoactivation by IPL (ALA-PDT. In this process there is pre-treatment with levulan which penetrates into the sebaceous gland and targets the porphyrins that the bacteria emit. Then the light homes in on the bacteria and destroys it.
Two recent studies in this area showed that a combination of red and blue light was better than either alone and that ALA-PDT was led to better improvement than radio-therapy-IPL or blue light activation.
Finally, the pulsed dye yellow laser hs been used successfully to treat severe acne.