Miscellaneous therapies/physical modalities: Recommendations

What is the effectiveness and what are the potential side effects of physical modalities for the treatment of acne vulgaris in adolescents to adults, including:

  • Intralesional steriods
  • Chemical peels
  • Comedo removal
  • Lasers and photodynamic therapy*

*Indicates a new clinical question for this guideline


  • There is limited evidence to recommend the use and benefit of physical modalities for the routine treatment of acne including pulsed dye laser, glycolic acid peels and salicylic acid peels.  
  • Intralesional corticosteroid injections are effective in the treatment of individual acne nodules.
  Strength of Recommendation  Level of Evidence 
Chemical peels  II,III 
Intralesional steriods  III 

Review prescribing information for recommended acne treatments.

There is limited evidence published in the peer-reviewed medical literature that addresses the efficacy of comedo removal for the treatment of acne despite its long-standing clinical use. It is, however, the opinion of the work group that comedo removal is often helpful in the management of comedones that are resistant to other therapies.

Studies exist suggesting that chemical peels may improve acne. However, large, multicenter, double-blinded control trials comparing peels to placebo and comparing different peels are lacking. Glycolic acid and salicylic acid chemical peels may be helpful for noninflammatory (comedonal) lesions.145-147,303,304 However, multiple treatments are needed and the results are not long-lasting. In the opinion of the work group, chemical peels may result in mild improvement in comedonal acne.

Some laser and light devices may be beneficial for acne, but additional studies are needed. Studies exist evaluating the use of many lasers, including pulsed dye laser, potassium titanyl phosphate (KTP) laser, fractionated and nonfractionated infrared lasers, and the fractionated CO2 laser. Light devices aside from lasers have also been investigated, including radiofrequency, intense pulsed light, photopneumatic therapy, and photodynamic therapy (PDT).

Of all laser and light devices, the most evidence exists for PDT in treating acne.305-308 With PDT, a photosensitizer, such as aminolevulinic acid, is first applied to the affected skin for a period of time (varying from 15 minutes to 3 hours). The photosensitizer is then absorbed into the pilosebaceous units and is preferentially taken up by sebocytes. A laser or light device is then used to activate the photosensitizer, generating singlet oxygen species, and thereby damaging the sebaceous glands and reducing P acnes. This treatment shows great promise, but additional studies are needed to determine the optimal photosensitizer, incubation time, and light source.

Intralesional injection of triamcinolone acetonide is a commonly used technique for the management of larger, nodular lesions in patients with acne.148,149 Rapid improvement and decreased pain are noted. Local atrophy, systemic absorption of steroids, and possible adrenal suppression may occur.309 Decreasing the concentration and the volume of steroid used will minimize these complications.

 


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