adam rish - laserase
TRANSCRIPT
Acne Treatment with
AGNES Micro-insulated Needle
RF system
Dr Adam Rish MBBS BMedSc BA(Hons) MFA FACAM FCPCA
and
Dr Gun Young Ahn M.D. Ph.D.
Gowoonsesang Clinic Seoul, Korea.
SPEAKER’S DECLARATION OF INTEREST Expenses to attend LCMC 2016
Registration, accomodation and
social functions paid DC
Conferences
Yes
Director in company associated
with presentation Kosmedical Pty
Ltd importer AGNES RF
Yes
Direct or indirect payment received
from company or organisation
associated with presentation
No
Direct or indirect payment received
from outside organisation or entity
to perform investigation being
presented
No
Past payment for services by
company or organisation
associated with presentation
No
Any other conflict of interest
relevant to the presentation. No
Acne Vulgaris • Self limiting (2-5years), fluctuating disorder pilo-sebaceous units
• Most adolescence F=M (M ++), later due to hormone disturbance
• Teens 20% with FH cf 10% no FH, twins 80% genetic 20% acquired
• Can leave lifelong pitted and/or hypertrophic scars
• May be psychologically disturbing to self-esteem (40% adolescents)
• Mix comedonesA, papulesB, pustulesC and nodulesD
Etiology
• Follicular epidermal hyperproliferation (+adhesion) (blocks gland)
• Excess sebum production (medium for culture bugs)
• Propionibacterium acnes activity (puberty 10/cm2 to 106/cm2 )
• Inflammation (white cells, pus, pigment, scarring)
Etiology • Androgen excess (DHEAS>DHT) in puberty (most normal range)
and menopause. Also androgen syndromes eg PCOS, adrenal hyperplasia and tumours (DHEAS>8000ng/ml)
• Decrease linoleic acid
• Increased interleukin-1
• Increased FGFR-2
Polycystic Ovary Syndrome • PCO 20%, PCOS (no cysts) 6% women
• Acne, hirsute, deeper voice, libido, amenorrhea
• Check Testosterone (>150ng/ml), SHBG, DHEAS, 17OH Progesterone, Prolactin, LH, FSH (LH/FSH >2 diagnostic), BSL
• Rx weight lost, antiandrogens (Spironolactone, Androcur, Cyproterone), Metformin to insulin resistance
• Reassess at 12 months
Clinical Findings
• Gradual onset lesion
• If sudden ?androgenic tumour, PCOS
• Main site face, back chest
• May scar: ice pickA, rollingB, boxcar, hypertrophicC
A B C
Medical Treatment
• Be aggressive enough to prevent scarring
• follicular keratin, sebum, P. acnes, inflammation
• Cleansers - medicated soaps eg pHisohex, Triclosan
• Keratolytics - salicylic acid .5-2%, azaleic acid (Finacea), retinoids
• Antibiotic gels - benzyl peroxide (inactivates retinoids), erythromycin, clindamycin, Bactroban, dapsone 5-7.5% gel
• Oral antibiotics - vibramycin 50mg m, minomycin 100mg bd
• Oral contraceptives +/- antiandrogenic eg Yaz, Diane 35 (DVT)
• Antiandrogens - Spironolactone 50-100mg (need OCP)
• Isotretinoin (Roaccutane) 0.5-1mg/kg/day, 20/52 (need OCP)
Acne
Pre-treatment Post retinal .1%
Roaccutane
• Actions: decrease sebum, seb. gland size, comedogenesis, P. acnes
• Low dose regimes less side effects equal efficacy: 10-20mg/day for 3-5/12 until resolved then 10mg/day for 2-4/12
• Females need negative BHCG, OCP - 1/12 pre. 1/12 post
• Side effects: teratogenic, dryness, blepharitis, alopecia, headache, muscle pain, LFT, hyperlipodaemia, neutropaenia, osteopaenia
• Issue depression hard to assess as in high risk group
• Recurrences common
Roaccutane
• In Australia S4 may be prescribed by GP on PBS but must comply with state laws which all say restricted to dermatologists
• May 2014 RACGP made case for GPs. ACD said bad idea!
• On 4 Corners in 2006 on suicide Campbell Bolton, treated with no GP referral, Dr Stephen Shumack said, “Dermatologists are dermatologists. We’re not specifically trained in assessing mental state of patients”
• In NZ GPs prescribe with no extra problems
• Why not GPs: they know patients, know OCP, and depression and are easy to get in to see (especially rural) and cost less money (? SfX as prescribing as availability)
OTC Medical Treatments
• Cleansers pHisohex, Triclosan soap
• Keratolytics salicylic acid .5-2% azaleic acid (Finacea) .01% tretinoin, retinal (in cosmeceuticals)
• Antibiotic gels - benzyl peroxide (Benzac)
• Hydroquinone 2% (if acne PIH) John Plunkett’s Superfade (with salicylic acid)
Diet • Uncertain link (poor early studies)
• Dairy and high glycaemic foods possible link
• Avoid foods that trigger
• Medications - steroids, phenytoin, lithium, high dose Vitamin B
Surgery
• Medical treatments better active acne as scars
• Don’t squeeze better Comedone remover eg Unna
• Use needle eg 24G to open pore
• Intralesional steroid (trimacinolone 5mg/ml) for nodular acne
• Undermining 19G needle good for scars
• Skin needling eg Dermapen good for scars
Microdermabrasion
Developed Mattioli 1985
Al oxide crystals blast skin, 20-90mmHg
Post 6 Mx
Skin Needling
Developed Des Fernandez
Roller with multiple .25mm needles
8 weeks post 1 Mx
Skin Undermining
6/12 post 3X 19G needle undermining + non ablative 1064nm laser
Chemical Peels Basics
equipment
Cross technique 100% TCA
Phototherapy • UV light beneficial (70% better in summer (?camouflage effect) • UVB kills P. acnes but poorly penetrates skin • UV 2x weekly helps but skin cancer • Phototherapy uses endogenous porphyrins or exogenous
(eg aminolevulinic acid (ALA) ) • Narrowband blue light (407-420nm) plus red light (goes deeper)
15 min, twice weekly, on face 4/52 - 60% lesions in 80% patients
Lasers and IPL
• KTP 532 nm 36% in acne when used twice weekly for 2 weeks
• IPL (400nm filter), Lasers of 1064nm, 1320nm and 1450nm can reduce active lesions with multiple treatments
• Nd:Yag 1064 at low fluence can reduce acne scarring
• Ablative lasers eg Fractionated erbium and CO2 remodel scars
Clinipro fractional CO2 Pre and post fractionated CO2 resurfacing
Efficacy YAG 1064nm and 1320nm
Lots of studies for 1064nm (107 Derm Surg) • Nonablative Acne Scar Reduction after a Series of Treatments with a Short-Pulsed 1,0
64-nm Neodymium:YAG Laser GRAEME M. LIPPER MD1,2, MARITZA PEREZ MD1,2,3
Dermatologic Surgery Volume 32, Issue 8, August 2006 = both effective YAG better
• Non-ablative subsurface remodelling: Clinical and histologic evaluation of a 1320-nm
Nd:YAG laser
Journal of Cosmetic and Laser Therapy 1999, Vol. 1, No. 3 , David J Goldberg
Clinipro 1064/1320nm Nd:YAG
Clinical-Lucas-Plus Q-Switched Nd:YAG
Reduced solar elastosis: Increased Collagen
Pre Post
Dermatol Surg 27:8:August 2001 Goldberg and Silapunt: q-switched nd:yag laser for wrinkles
Mode of Action
• Uncertain
• Results at 1 hr direct heating effect = ?oedema
• Longer effects as increased collagen stimulation
• Skin at 47C for 20 min burns
• Q Switch no heat damage as such a fast temperature rise - but skin “thinks” it is burnt and releases heat shock proteins causing remodelling
• Low fluence 3+J/cm2 comfortable and results
• Like flicking a switch above a threshold pushing harder does not make the light turn on better
Treatment modalities for acne
Temporary Methods
1. Topical agents
2. Oral medications
3. Medical skin cares
4. Chemical peelings
5. Lasers
6. PDT
Permanent Methods
1. AGNES (Selective sebaceous gland destruction, Kobayashi method)
AGNES
Handpieces for acne Tx for melting & skin tightening
Micro-insulated Needles
Acne
Syringoma
Blackhead
Eye bag
Wrinkle
No sebaceous gland, no acne
Destroy the sebaceous gland
without epidermal burn = SSGD
Selective Sebaceous Gland Destruction
Should I destroy every sebaceous gland?
No.
“Acne usually relapses from the same follicles”
“Of 200,000 pilosebaceous units on face less than 10% acne prone”
Acne prone follicles
narrow area of the infundibulum
vulnerable to obstruction with androgenic stimulation
severe inflammation of the infundibulum
scarring as a sequela.
Distance from surface to SG 500μ
400 Mm
500~600 Mm
Hair follicle with Normal sebaceous gland
(normal)
Conditions for Selective Sebaceous Gland Destruction
1. Protect 400 Mm
The distance from skin surface to sebaceous gland should be
insulated
2. Non-insulated part should be longer than 1000 Mm (1mm)
As sebaceous hyperplasia in acne
3. RF energy should increase the temperature over than 70 °C
sebaceous gland is a kind of fatty tissue
4. Minimal damage to surrounding tissues
High peak power with short pulse duration
Square pulse > Sign wave form
Fat tissue has low conductivity
Reaching to the melting point of fatty tissue needs about 10 times higher than wet skin.
Partially insulated microneedle of AGNES
Stopper
Partially insulated micro-needle
AGNES TEST
Insulated Non-insulated
Easy checking of insulation status
Studies
Normal human sebaceous gland
Animal study
Clinical study
International J. Dermatol. 2012. 51. 339-344
Selective sebaceous gland electrothermolysis as a treatment for acne: a prospective pilot study
Gun Young Ahn, In Woong Lee, Beom Joon Kim, Myeung Nam Kim, Hiromi Aso
Materials for prospective study
• Patients
– Twelve patients with moderate to severe facial acne
– 6 males and 6 females, ages from 20 to 32 years (24.6±3.4)
– Fitzpatrick type III-V
– No medications, no peelings during the study
– Exclusion criteria for candidates
• Oral antibiotics or isotretinoin within previous 6 months
• Use of topical or antibiotics or retinoids within previous 2 weeks
• Oral contraceptive with anti-androgenic properties less than 12 weeks
• Pregnancy and lactation in female patients
Methods
• Procedure
– Application of topical anesthetic cream prior to procedure
– Identifying acne lesions
– High frequency current was applied for 0.12 to 0.50 seconds at an intensity of approximately 40W
– The next day or the day after following the procedure, the contents of lesions were eliminated by acne extractor with gentle pressure
– Total 3 sessions of treatments were performed for 1~3/12 intervals
Methods • Evaluation
– Before and after each treatment session, 1 month and 1 year after the final treatment
• Overall success rate (Investigator’s global severity assessment)
– Clear or almost clear
• No. of lesions
– Photo
– Inflammatory and non-inflammatory lesion
• Adverse events
• Patients’ satisfaction score
– 4, very satisfied; 3, satisfied; 2, slightly satisfied; 1, unsatisfied
Results
• Overall success rate
– All patients (100%) were Grade 0 or 1 (at 1 month after the final
treatment)
Rating Definition
0 - Clear Residual hyperpigmentation and erythema may be present
1 - Almost clear A few scattered comedones and a few (less than five) small papules
2 - Mild Easily recognizable; less than half the face is involved. Many comedones and
many papules and pustules
3 - Moderate More than half of the face is involved. Numerous comedones, papules
and pustules
4 - Severe Entire face is involved. Covered with comedones, numerous papules and pust
ules and few nodules and cysts
5 - Very severe Highly inflammatory acne covering the face; with nodules and cysts
present
* Investigator’s global severity assessment (IGA)
Results • Lesion counts (inflammatory and non-inflammatory acne)
– 61.1% (1st) 82.2% (2nd) 96.3% (3rd) reduction in inflammatory lesions
– 49.3% (1st) 69.0% (2nd) 83.3% (3rd) reduction in non-inflammatory lesions
Inflammatory lesions Non-inflammatory lesions
Results Patients’ satisfaction score
– 3.50±0.67
Adverse events
– Transient erythema at the treated site; most common
– No other severe adverse events
Relapse: 2 of 12 patients at 1 year after last treatment
– Mild acne
Slightly satisfied, 8
(1)
Satisfied, 33 (4)
Very satisfied, 59
(7)
Unsatisfied, 0
Slightly satisfied
Satisfied
Very satisfied
Unsatisfied
Conclusion
1. Long-term cure rate & low recurrence rate for acne
2. Only 3 times of Tx. are needed in most of patients.
3. Solution for acne patient who does not want oral medication
4. No systemic side effect
5. Initial training is important
6. No facial dryness (not as in PDT, isotretinoin)
Protocol for SSGD
Step 1. Empty the hair follicles.
– Complete extraction of sebum using acne
extractor by nurse
Step 2. Destroy the sebaceous glands.
– using microinsulated needle by doctor
Step 3. Removal of debris & exudates
- within 3 days by nurse
Step 1. Empty the hair follicles.
- by Nurse/Aesthetician
Step 1. Empty the hair follicles.
1. Wearing the magnifying loupe.
2. Making the hole with 21G needle with proper direction.
3. Extraction with gentle pressure with Unna comedone
remover.
Pucture technique
Good Bad
Step 2. Destroy the sebaceous glands.
- by Doctor
Inflammatory acnes
Acne Treatment by AGNES
Step 3. Removal of debris & exudates within 3 days
- by Nurse/Aesthetician
1. Melting the debris of seb. gl. for reduce the pain while extraction
2. Promoting wound healing by bipolar energy
–> collagen remodeling
Clinical Photos (long term follow up)
22/F Before 3 month after the 1st Treat. 1 month after the 1st Treat.
1 year after the 1st Treat. & Before the 2nd Treat.
6 month after the 1st Treat. 6 month after the 2nd Treat.
AGNES AGNES AGNES
AGNES AGNES AGNES
8 month after the 1st Treat. & Before the 2nd Treat
F/25 Before 6 month after the 2nd Treat.
AGNES AGNES AGNES
F/27 Before 5 month after the 2nd Treat. & Before the 3rd Treat
2 month after the 1st Treat. & Before the 2nd Treat
4 month after the 3rd Treat. & Before the 4th Treat.
AGNES AGNES AGNES
AGNES
1 month after the 1st Treat. & Before the 2nd Treat
Immediate after
2 month after the 3rd Treat. & Before the 4th Treat.
1 month after the 2nd Treat. & Before the 3rd Treat
F/29 Before
AGNES AGNES AGNES
AGNES AGNES
F/30 Before 6 month after the 2nd Treat. 2 month after the 1st Treat.
& Before the 2nd Treat
2 year after the 2nd Treat. & Before the 3rd Treat.
15 month after the 2nd Treat.
AGNES AGNES AGNES
AGNES AGNES
F/30 Before 4 month after the 2nd Treat.
1 month after the 1st Treat. & Before the 2nd Treat
1 year after the 2nd Treat. & Before the 3rd Treat.
8 month after the 2nd Treat. 9 month after the 3rd treat.
AGNES AGNES AGNES
AGNES AGNES AGNES
Before
Indications
1. For Sebaceous gland disorders
– Acne
2. For Eccrine gland disorder
– Syringoma
3. For Wrinkle
– Periorbital
– Perioral
4. For Eye Bag (Infraorbital fat herniation)
5. For Scar
- Deep ice-peak type scars, smallpox scars
6. For Double chin
For deep scars
No down time
No redness
No scabs
5 mo. After 1st session Smallpox scar (before)
Smallpox scar (before) 6 mo. After 2nd session
Syringomas treated by intralesional insulated needles without epidermal damage
Ann Dermatol. 2010 August; 22(3): 367–369.
Before
3 mo. after 2 sessions
For eye bags
3/7 down time
with redness and swelling
May need LA - bruise
Before
Before
For fine wrinkles
1/7 down time
with redness
Thank you