CO2 laser combined with ALA-PDT for successful treatment of refractory acne vulgaris: A case report.

Dear editors, Acne vulgaris is a common skin disease of showing alteration of the keratinization process causing the progression from comedone formation to inflammatory response.1 Generally, acne vulgaris clinically responds well to the treatments such as salicylic acid, antibiotics, and/or combination with isotretinoin. However, in some individuals, acne vulgaris does not response to topical treatments or oral pharmacological interventions.2 Thus, these individuals with treatmentresistant acne vulgaris, socalled refractory acne vulgaris (RAV), require alternative options for the effective treatment. A 22yearold male patient presented to our dermatology outpatient unit with a 4year history of bilaterally facial acne vulgaris. Clinical examination showed a large number of comedones fused into one piece with inflammatory lesions on his faces (Figure 1A). The patient reported no respond to the treatment with oral isotretinoin (0.5 mg/kg/day). Therefore, the combinations of oral isotretinoin (0.5 mg/kg/day) and topical 30% salicylic acid (six times, one time per 2– 3 weeks) or alpha hydroxyl acid with adapalene gel as well as clindamycin hydrochloride and metronidazole liniments were initially used to treat the patient. After 3 months, the numbers of inflammatory lesions were slightly decreased. However, the patient reported a recurrence of superficial acne, and no alteration of the deep acne was observed (Figure 1B). Given an unsuccessful treatment with mediations, CO2 laser therapy was subsequently selected as an alternative treatment following the patient stopped taking medications for 2 weeks. The patient was treated with an ablative 10,600 nm fractional CO2 laser systems (Chongqing Jingyu Laser Technology Co., Ltd). Meanwhile, needle acupuncture was used to extrude fat plugs following CO2 laser therapy. After 2 months, the large facial acne still existed, though part of the comedones disappeared, and decreased numbers of inflammatory lesions were also observed (Figure 1C). Due to previous unsatisfactory curative effect, CO2 laser combined with 5aminolaevulinic acid photodynamic therapy (ALAPDT) were further performed. The treatment process showed as follows: CO2 laser described as above was used to vaporize the tip of comedones to form small pores, and the fat plugs were extruded by using needle acupuncture. Topical 5% ALA was immediately applied, and sterile cottons soaked with 5% ALA were covered bilaterally facial surface for 2 h. Then, Light irradiation was carried out by exposing the bilaterally facial surface to a red LED device (640 nm, Shenzhen Pumen Technology Co., Ltd) at the dose level of 72 mw/cm2 for 20 min, followed by cooling with ice for 2 h. The treatment was performed every 2 weeks. After 3 times of treatment, the facial acne was significantly improved with few inflammatory lesions and some scattered erythema and sunken acne pits (Figure 1D). The halfyear followup medical examinations showed only some sunken acne pits and no recurrence of the facial acne (Figure 1E). The patient was satisfied with the result. Oral isotretinoin or topical pharmacological interventions is the treatment of choice for acne vulgaris.3 Nevertheless, no significant clinical response was observed while the patient was treated with mediations. Recent years, there is growing interest in laser, energy, and lightbased minimally invasive treatment of acne vulgaris, which may be considered to provide a relatively safety treatment for patients.4 CO2 laser therapy has achieved clinical improvements in acne scars, for CO2 laser could break and gasify the closed tip of comedones to form relatively deep pores to prompt drug absorption.5 Here, we observed that the numbers of acne and inflammatory lesions were reduced using CO2 laser therapy. However, the large facial acne could not be eliminated, suggesting that RAV does not response adequately to the treatment with CO2 laser therapy alone. ALAPDT has been widely used to treat skin diseases and known to be effective and safe to severe acne vulgaris.6 However, the application of ALAPDT in the treatment of RAV remains scare.7,8 Given a strong potential of ALAPDT to inhibit the growth and lipid secretion of sebaceous gland cells as well as its antiinflammatory effect, ALAPDT could be fundamentally used to solve the problem of acne recurrence. Meanwhile, the pores formed by CO2 laser gasification were conducive to the penetration of ALA and the extrusion of fat plugs, which would further improve the therapeutic effect of PDT. Thus, CO2 laser combined with ALAPDT was used to treat RAV. Expectedly, the RAV of the patient was significantly improved with tolerable side effects including redness, skin scab, and dry peeling without pigmentation. Moreover, no recurrence of the facial acne was observed for half a year, suggesting that CO2 laser combined with ALAPDT can achieve good therapeutic effect for RAV. In conclusion, our case suggests that CO2 laser combined with ALAPDT may be considered for the treatment of RAV unresponsive to pharmacological interventions. Certainly, further study is warranted.