Microneedling and CO2 Lasers Enhance Acne Treatment

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While topical or systemic antibiotics and retinoid formulas were previously common treatment for acne, studies show prolonged use can result in issues such as antibiotic resistance or other adverse events.¹ More recent guidelines recommend photodynamic therapy with 5-aminolevulinic acid (ALA-PDT) as a first-line treatment for moderate to severe acne, supported by strong evidence.² However, ALA-PDT's effectiveness is limited to superficial skin layers. To enhance its penetration, pretreatment methods like microneedles and CO2 fractional lasers are used. Microneedles create small punctures in the skin, and CO2 lasers generate micro-thermal zones to improve drug absorption.³

A recent study aimed to evaluate the combined effectiveness and safety of CO2 fractional laser and microneedle pretreatment with ALA-PDT for treating moderate to severe acne, using the Global Acne Grading System (GAGS) to measure results. Researchers found that both the CO2 fractional laser and the microneedling subgroups saw improved efficacy, with the CO2 fractional laser group seeing fewer adverse events.⁴

Patients and Treatment Plans

The study included 150 patients, all who had moderate to severe acne based on Chinese diagnostic guidelines. Patients were randomly assigned to 3 groups:

• Group A: Received ultra-pulsed CO2 fractional laser treatment with specific settings for one session.
• Group B: Underwent microneedling with a device and depth designed to induce swelling and minor bleeding.
• Group C: Received no pre-treatment.

All groups were then treated with 20% ALA gel followed by photodynamic therapy (PDT) with a red light for 30 minutes. Treatments were administered weekly for 3 weeks. Efficacy was evaluated after 4 weeks, with follow-ups every 12 weeks.

Results

The study stated that all 150 patients completed the treatment. Researchers reported that group A (CO2 fractional laser) had an 88% effectiveness rate, group B (microneedling) had a 62% effectiveness rate, and group C (no pre-treatment) had a 36% effectiveness rate, with “significant” differences between the groups (P < 0.05). Group A was reported to be significantly more effective than groups B and C (P = 0.046 and P < 0.001, respectively), and group B was also more effective than group C (P < 0.001).

Before treatment and 1 week after, there were no reported differences among the groups (P > 0.05), but researchers stated “significant” differences were observed at 2 weeks and at the end of the 4th week (P < 0.05). At the 12-week follow-up, no relapses occurred, and many patients continued to improve.

Safety Considerations

The study stated that there were no severe adverse events. The incidence of minor adverse events was 36% in group A, 46% in group B, and 34% in group C. Researchers observed common issues included burning sensations, skin dryness, desquamation, erythema, and hyperpigmentation, which were generally manageable with moisturizers and light avoidance. One patient in the CO2 fractional laser group reportedly developed hypertrophic scars. Pain levels, assessed using the Visual Analog Scale (VAS), did not differ significantly among the treatment groups (P = 0.757). Overall, researchers found all patients tolerated the treatments well and completed the course.

Conclusion

This study confirmed that ALA-PDT effectively treats moderate to severe acne, with CO2 fractional laser pretreatment showing the highest efficacy (88%) compared to microneedling (62%) and no pretreatment (36%). Both pretreatment methods enhanced the effectiveness of PDT by improving drug absorption and skin regeneration, though Researchers found CO2 fractional laser had fewer adverse events and superior results. The study's short duration and lack of long-term monitoring limit conclusions on sustained efficacy, which could be explored in future research.

References

1. Walsh TR, Efthimiou J, Dréno B. Systematic review of antibiotic resistance in acne: an increasing topical and oral threat. Lancet Infect Dis. 2016;16(3):e23-e33. doi:10.1016/S1473-3099(15)00527-7
2. Shi L, Wang H, Chen K, et al. Chinese guidelines on the clinical application of 5-aminolevulinic acid-based photodynamic therapy in dermatology (2021 edition). Photodiagnosis Photodyn Ther. 2021;35:102340. doi:10.1016/j.pdpdt.2021.102340
3. Ahmed Saeed Al-Japairai K, Mahmood S, Hamed Almurisi S, et al. Current trends in polymer microneedle for transdermal drug delivery. Int J Pharm. 2020 Sep 25;587:119673. doi: 10.1016/j.ijpharm.2020.119673. Epub 2020 Jul 30.
4. Liu Y, Sun DD, Chang SY, et al. Study of different pre-treatments in the comparison of the efficacy of photodynamic therapy for moderate to severe acne vulgaris. Photodiagnosis Photodyn Ther. July 30, 2024. doi:10.1016/j.pdpdt.2024.104298