Title

Is Blue Light Therapy More Effective than Aminolevulinic acid (ALA) PDT at Reducing Acne
Lesions and Severity in Moderate to Severe Acne Graded with Global Acne Grading System
(GAGS)?

What is acne
 Acne is a multifactorial disease involving the high sebum secretion rate with a reduce
level in linoleic acid, follicular hyper cornification, colonization of P. acnes and
inflammation.

Figure 1. Acne Vulgaris

Figure 2. Moderate to severe acne vulgaris

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Epidemiology of Acne
 As the most common skin disease, acne has a prevalence of 35%-90% in adolescents.
 Peaks between the age of 14 to the beginning of third decade. However, the
condition may persist until late adulthood with a prevalent of 20% men and 35%
women.

Pathophysiology of Acne
The lesion begins with the following cascade:
1. Increased sebum secretion
2. Follicular hyperkeratinisation and microcomedones formation
3. Enlargement of comedones progressing into closed and open comedones
4. Blockage of the follicle exacerbating the colonization of anaerobic bacteria
5. Inflammatory response and lesion development

Acne Vulgaris
 Acne Vulgaris is the most prevalent with 99% of acne cases.
 Lesions can range from being comedones, papules, pustules, nodules, cysts and
associated scarring.
 Other types of acne are acne conglobate, acne excoriee, acne rosacea, acne cosmetic
and others.

Figure 3. Range of acne

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Acne as a Wound
 60% of acne sufferers have a self-limiting condition with a long-term sequence.
Reviews found that acne can lasts up to three to five years therefore is considered as
an inflammatory chronic condition.
 Epidemiology of acne, clinical course of acne, the pharmacoeconomics and
psychosocial impact of acne also supports the fact that acne is a chronic disease.

Grading System for Acne

 Global Acne Grading System (GAGS) allow allied health professionals to compare
cases more accurately thus produces more effective interventions and treatments.
 Utilizing acne severity grading system also acts as a clinical feature in which clinicians
provide treatment recommendations. Additionally, the chosen acne severity
assessment implement practicality, accuracy and time efficiency.

Figure 4. Global Acne Grading System

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Psychological Impacts of Acne
 Even though acne does not bring direct physical impairment, it often gives a massive
psychosocial burden to the sufferers.
 This impact is particularly higher in moderate to severe acne sufferers due to the risk
of scarring.
 The presence of acne lesions as well as scarring lead to social phobia, low self-image,
anxiety and depression.
 Those suffering from severe to very severe acne graded with GAGS will have higher
chance of suicidal ideation compared to mild acne.

Management Strategies and Education

 Due to the psychosocial burden in acne sufferers, clinicians need to be aware of the
condition by:
- Being aware of the patient’s psychological concerns and how it impacts their
social lives.
- Ask about experiences and successes with any treatments that have been used to
manage the condition (include over the counter drugs, cost vs benefits and
pharma-economic).
- Educate patients with information on acne, dispel myths and provide advice on
skincare and treatment interventions according to the severity.

Treatments (Subheading: Antibiotic Resistance)

 With the increasing prevalence of antibiotic resistance P. acnes, the efficacy of
antibiotic treatments is reduced as a consequence.
 The emergence of resistant strains is due to the frequent and long term used of
topical and/or systemic antimicrobials.
 Not only this will result in the development of P. acnes strains with cross resistance to
various antibiotics, further implications of diseases where P. acnes act as the
causative pathogen as well as possible resistant to other bacterial species may also
occur.

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Treatments (Subheading: 3.6% Topical Aminolevulinic acid (ALA) PDT)
 A two-step process involving the application of photosensitizer to selectively
accumulate the target tissue after local or systemic administration. This process is
then followed by activation of light in the presence of oxygen to initiate chemical
reactions that generate cytotoxic species therefore destroys the pathogenic bacteria.
 Research found that 12/125 participants experienced mild to moderate
desquamation at the treated side.
 Meanwhile, 66/125 participants mentioned painful feelings post treatment, 82/125
experienced moderate erythematous erythema, 12/125 had mild to moderate
desquamation at the treated side and 26/125 mentioned temporary
hyperpigmentation that disappeared after one or two months without any further
interventions.
 Lastly, none developed ulcers, infection, purpura, scarring or other adverse effects.

Figure 5. Before and after using ALA-PDT

Treatments (Subheading: Blue Light Therapy 407-420 nm)

 Has a bactericidal effects on P. acnes
 Reduced sebum production, reduced sebaceous gland size and attenuated
inflammatory cells infiltrations were observed post exposure to 415 nm blue light
treatment.
 Studies found that P. acnes viability was reduced by 15.7% and 24.4% immediately
after 60 minutes’ irradiation in moderate to severe acne sufferers.

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Figure 6. Before and after using blue light therapy

Comparison between ALA-PDT and Blue Light Therapy

20 patients with moderate to severe acne graded with GAGS were treated with four sessions
of 10% ALA-PDT on the right side of the face and 415 nm blue light on the left side of the
face.

Weeks Reduction (%) ALA-PDT Reduction blue light alone

(%)
4 32 20.7
8 50.9 27
12 65.9 57.7
16 71.1 56.7
Table 1. Comparison of reduction between ALA-PDT and blue light alone

Adverse effect reported after both treatments are

Adverse Effects ALA-PDT (%) Treated Side Blue Light Treated Side (%)
Stinging 50 25
Pain 20 10
Erythema 65 30
Peeling 70 60
Pruritus 65 50
Table 2. Comparison of adverse effects post treatment between ALA-PDT and blue light alone.

Hence, we can conclude that ALA-PDT treated side has higher side effects or adverse
reactions despite of the higher reduction of P. acnes in comparison to the blue light
treated side.

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Combination of ALA-PDT and Blue Light Therapy
 Studies found that ALA-PDT with light therapy was effective in reducing the number
of inflamed lesions in patients with moderate to severe acne vulgaris compared to
individual treatment, with little to no adverse effects.
 This is due to P. acnes producing porphyrins that are activated by visible light and
induces a photodynamic reaction that kills the pathogenic bacteria.

References (nanti aja ditambahin)

Tien-Yi Tzung, Kuan-Hsing Wu, & Mei-Lun Huang. (2004). Blue light phototherapy in the treatment
of acne. Photodermatology, Photoimmunology & Photomedicine, 20(5), 266–269. https://doi-
org.wallaby.vu.edu.au:4433/10.1111/j.1600-0781.2004.00109.x

Dessinioti, C., & Katsambas, A. (2017). Propionibacterium acnes and antimicrobial resistance in
acne. Clinics in Dermatology, 35, 163–167. https://doi-
org.wallaby.vu.edu.au:4433/10.1016/j.clindermatol.2016.10.008