ARTICLE IN PRESS

Medical Laser Application 23 (2008) 141–146

www.elsevier.de/mla

Combination light therapies for the treatment of acne: An overview

and introduction to photopneumatic therapy
Girish S. Munavallia,, Robert A. Weissb
a
Dermatology, Laser, and Vein Specialists of the Carolinas, 1918 Randolph Road, Suite 550, Charlotte, NC 28207, USA
b
Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore MD, USA

Received 5 May 2008; accepted 7 May 2008

Abstract
Acne is a very prevalent skin disorder and several devices (such as blue light, pulsed dye laser, diode laser, LEDs,
RF, and pulsed light) have been reported to have varying degrees of efficacy for treatment. Pulsed light treatments
have been used both alone and in combination with other modalities to rapidly reduce active acne. Photopneumatic
therapy is a novel technology that combines pneumatic energy with a pulsed light source to manipulate the optical
characteristics of the skin. A vacuum suction raises target structures in the dermis closer to the surface of the skin prior
to exposure of light, allowing for extrusion of sebaceous material from the pilosebaceous apparatus. Recent studies
have shown promise regarding the use of photopneumatic therapy for the treatment of acne vulgaris.
r 2008 Published by Elsevier GmbH.

Keywords: Acne; Phototherapy; IPL; Photopneumatic therapy (PPx); Light

Introduction impact. The first involves the severity of disease and

Acne vulgaris is a common skin disease affecting more
than 85% of adolescents, and often continuing into
adulthood. Active acne and its sequella, especially
permanent scarring, may cause longstanding psycholo-
gical or emotional harm in patients. Evidence suggests
that the impact of acne on a patient’s psychological and
emotional well-being is comparable with that of
systemic disease processes such as diabetes, asthma,
arthritis, and epilepsy [1].
Quality of life measurements are often used to
determine the severity of impact of a disease. In patients
with acne, two factors are reported to have a significant
Corresponding author. Tel.: +1 704 375 6766;
fax: +1 704 332 6552.
E-mail address: gmunava@yahoo.com (G.S. Munavalli).
varies from patient to patient. The degree of severity
should be considered from both the physician’s and
patient’s perspective [1]. Closely related to this, the
second factor involves the age of the patient. Although
the overall prevalence of acne does decline with age in
both sexes, a significant number of individuals experi-
ence either a worsening of acne symptoms or fail to
experience improvement after their teenage years.
Multivariate analysis has shown that the increasing
age of affliction of patient can proportionately affect the
quality of life [2,3].
Although a clinical diagnosis of acne is usually readily
made from examination, prescribing effective treatment
can be challenging. Medical mainstays of treatment,
including topical treatments such as retinoids and oral
medications such as minocycline, are effective but have
potential drawbacks including patient compliance, side

1615-1615/$ - see front matter r 2008 Published by Elsevier GmbH.

doi:10.1016/j.mla.2008.05.001
 ARTICLE IN PRESS
142 G.S. Munavalli, R.A. Weiss / Medical Laser Application 23 (2008) 141–146

effects, and longevity in terms of onset of action. Patient
variability is also an important factor to consider in
efficacy. For example, patients with acne and extremely
greasy skin tend to be less beneficially helped by oral or
topical medications [4].
Current research indicates that the pathogenesis of
acne involves four main processes: follicular hyperpro-
liferation, excess sebum production, inflammation, and
proliferation of Propionibacterium acnes. Effective
treatments should target and suppress several of these
processes simultaneously for maximum benefit [1]. For
the past decade, intense research interest has developed
in combining in-office device treatments with standard
medical treatments to achieve rapid and long-lasting
improvement in acne. This concept was made possible
through an evolving understanding of laser–tissue
interaction involving bacterial skin flora, porphyrins
and sebum, and the development of a variety of new
lasers, light sources, and radiofrequency devices [5].
Additionally, late adolescent and adult onset acne
provided a patient group with a strong desire for rapid
regression of acne lesions and with an age and maturity
level capable of tolerating more involved, office-based
treatments. This report will focus on light devices, both
alone, and in combination with other simultaneously
applied methods, for the treatment of facial acne.
It has been a recognized fact for some time that
sunlight helps to clear acne-laden skin. Ultraviolet and
visible blue light from this form phototherapy have been
postulated to be destructive to bacterial skin flora and
suppress inflammatory skin processes, although the
exact role of phototherapy was unclear [5]. Ultraviolet
light, with and without the application of psoralen, was
the first light source to be studied and showed mixed
results, although the risks clearly outweighed the
benefits [6,7]. More recently, visible light sources have
been evaluated and include both continuous wave and
pulsed light devices. The first of these to be studied was
continuous wave blue light, due to the inherent ability of
wavelengths in the 407–420 nm range to activate
endogenous porphyrins in acne-pathogenic bacteria
such as P.acnes. In so doing, selective targeted destruc-
tion could decrease the pathogenic bacterial load on the
skin surface.
Continuous wave visible light
Shalita et al. were among the first to evaluate the use
of a metal halide lamp with a wavelength of 405–420 nm
(ClearLight, Lumenis Ltd., Santa Clara, CA) for acne
treatment using twice weekly exposures of short (10 min)
irradiation duration. Thirty-five subjects with lesions on
the face and back were treated over a 4-week period;
80% demonstrated improvement of non-inflammatory,
inflammatory, and total facial lesions with a 70% mean
decrease in inflammatory lesion count 2 weeks after the
last treatment [7]. Using the same or similar continuous
wave blue light devices, other investigators showed a
marked improvement in facial acne [8–11].
Pulsed light devices (IPL)
Pulsed light devices were the next non-collimated,
non-coherent light sources to be utilized on active acne.
Investigators postulated that a broadband light source
with cut-off filters above 500 nm would activate
endogenous porphyrins (albeit to a lesser degree than
blue light, noticeable due to decreased absorption), but
would also have an effect on erythema due to absorption
in the 590–650 nm range. A noticeable improvement has
been reported with these devices [12,13]. More recently,
pulsed light has been investigated for the treatment of
acne in Asian skin. Chang et al. used a pulsed light
device with a cut-off filter between 530 and 750 nm to
treat inflammatory acne and post-acne-related erythe-
matous lesions. Patients were randomized to a split-face
treatment, using benzoyl peroxide as the control.
Results showed a decrease in lesion count on both sides
with no statistical difference; however, the pulsed light-
treated side was noted to have marked improvement in
acne-related sequel such as post-inflammatory erythema
and hyperpigmentation. Notably, the safety of pulsed
light devices for treatment in darker skin types was
established [14]. On a practical note, all pulsed light
devices that emit wavelengths in the range of the
aforementioned cut-off filters have the potential to
cause permanent hair loss if treatments occur in dark-
colored hair-bearing areas.
Pulsed light combined with aminolevulinic acid
(ALA)
Interest in light-based treatments for acne was
renewed with the onset of light and topical photo-
sensitizing medication combination treatments. Termed
photodynamic therapy (PDT), investigators coupled the
application and activation of aminolevulinic acid (ALA)
with pulsed light in order to selectively and more
effectively target skin-surface bacteria. Exogenously
applied ALA is converted to protoporphyrin IX (Pp
IX) in more metabolically active entities such as
bacteria, and destruction occurs due to photon excita-
tion and in-situ singlet oxygen free radical formation
[15,16]. Sebaceous glands also were targeted for destruc-
tion due to preferential uptake of ALA and irradiation
by the deeper reaching near-infrared and infrared
wavelengths above 800 nm [17]. A landmark prospective
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G.S. Munavalli, R.A. Weiss / Medical Laser Application 23 (2008) 141–146 143

study by Hongcharu et al. using 5-ALA and a broad-
band 550–700 nm light source at a fluence of 150 J/cm2
showed a decrease in acne lesions [18]. This effect
persisted for 10–20 weeks after 1–4 treatments. The
authors also demonstrated a decreased sebum excretion
rate and decrease sebaceous gland size. In addition, they
demonstrated decreased counts of follicular bacteria.
Adverse effects noted in the study were those typical of
long contact ALA-PDT treatment, including erythema,
crusting, pain, and hyperpigmentation. More recently,
other investigators showed improvement in acne using
PDT with blue light as the activating source [19–21].
To further elucidate the role of pulsed light, split-face
comparisons were done with pulsed light alone vs. ALA/
pulsed light PDT for efficacy in acne treatment. Santos
et al. [22] noted decreased lesion counts and more longer-
lasting improvement in acne on the ALA/pulsed light side
compared to pulsed light irradiated side alone. More
recently, Yeung et al. were among the first to report a
statistically significant improvement in the number of
non-inflammatory acne lesions on the PDT/pulsed light-
treated side in a split-face comparison with pulsed light
alone and a control group. Interestingly, they found there
was no difference in the amount of improvement of
inflammatory lesions in the three groups [23].
Combined pulsed light with radiofrequency (RF)
Pulsed light has also been combined with radio-
frequency heat in the treatment of acne. Prieto et al. [24]
treated 32 subjects with a combined pulsed light/
radiofrequency device and showed a statistically sig-
nificant reduction in lesion counts. Additionally, on
histologic evaluation, they showed that improvement
may be partly due to reductions in both perifollicular
inflammation and sebaceous gland areas. Taub [25]
found pulsed light activation of ALA for acne treatment
to be better than pulsed light plus radiofrequency or
blue light in a comparative study with superior 1 and 3
month lesion count reduction in the patients receiving
pulsed light activation.
Photopneumatic therapy (PPx)
The most recently reported pulsed light combination
treatment for acne utilizes vacuum or pneumatic
pressure in simultaneous application with light. Of
historical note, the use of vacuum suction for the
treatment of acne was first described in the dermatology
literature by Moschowitz [26], who described the
treatment of eight subjects with a rubber bulb to apply
slight suction to acne lesions so as to cause localized
hyperaemia. Two newly introduced devices have been
designed with the ability to apply vacuum concurrently
with light.
The first device functions by mechanically clearing
congested follicles of the affected pilosebaceous appa-
ratus using suction-applied disposable tip while utilizing
broadband light with a cut-off filter from 405 to
1100 nm to activate endogenous porphyrins in patho-
genic bacteria. Following treatment, ultrastructural
histologic analysis shows the bacteria has undergone

Fig. 1. When complete contact with the treatment tip and the skin is achieved, negative pressure is applied to the skin (far left).
Dermal structures such as the sebaceous gland are drawn towards the epidermis. Congested sebum and hyperkeratotic tissue is
ejected through a dilated follicular orifice onto the skin surface (middle left). Light is radiated onto the skin surface, typically in the
range 5–9 J/cm2 irradiating the treatment area, including the sebaceous gland and the surrounding pilosebaceous apparatus (middle
right). Vacuum suction and light are turned off and the skin returns to a normal position (far right).
 ARTICLE IN PRESS
144 G.S. Munavalli, R.A. Weiss / Medical Laser Application 23 (2008) 141–146

Fig. 2. A 16-year-old Asian male patient was treated with two treatments with a 1-week interval between treatments.

Fig. 3. The schematic image depicts the action of the PSF

device on this skin. Upward compression is applied, resulting
in flattening and elevation of skin structures.

thermal damage [27]. Termed photopneumatic therapy,

the IsolazTM (Aesthera Corp, Pleasanton, CA) is
capable of generating vacuum with up to 3 psi pressure
in a confined treatment area which effectively lifts the
dermal structures towards the epidermis and expels
follicular contents onto the skin surface (Fig. 1).
Shamban et al. [28] demonstrated in a multicenter
retrospective study efficacy in the physician-rated mean
clearance of mild to severe acne ranging from 50%
following a single treatment, up to 90% following four
treatments. In the authors experience in performing over
150 treatments, marked improvement can be seen after
as few as two treatments spaced 2 weeks apart (Fig. 2).
Another pneumatic skin flattening (PSF) device has
been developed to be retrofitted onto the tip of existing
Fig. 4. The upper, obliquely oriented black rectangular box
highlights the treatment area following an IsolazTM treatment.
Note the ejection of sebum. The lower rectangular box contains
the treatment area following application of the PSF tip. (Image
courtesy of Vic Narurkar, MD, San Francisco, CA.)
laser and pulsed light devices (Innolase PSFTM, Candela
Corp, Wayland MA) (Fig. 3). Lask et al. [29] demon-
strated using a post-treatment questionnaire, a sensation
of decreased pain in patients receiving treatment for
laser hair removal with a diode laser with the PSF as
compared to adjacent controls. However, for the
treatment of acne, there have been no published reports
 ARTICLE IN PRESS
G.S. Munavalli, R.A. Weiss / Medical Laser Application 23 (2008) 141–146
of efficacy with devices using this system. Because of the
flat plate design of the device and constant flush contact
with the skin during treatment, extrusion of sebum
through occluded follicular orifices is not possible
(personal communication Vic Narurkar, MD) (Fig. 4).
In conclusion, these are exciting times for research
into devices for the treatment of acne. Photopneumatic
therapy is a promising new modality for the treatment of
acne. However, further study is required about this
method. It is of note that a recent analysis evidence-
based review by Haedersdal et al. [30] of light and laser-
based device studies for acne remarked that the majority
of light-based devices show short-term improvement
and the most consistent outcomes to date have been seen
with photodynamic therapy.
Zusammenfassung
Kombinierte Lichttherapien für die Behandlung von Akne:
Eine Übersicht und Einführung der Photopneumatischen
Therapie
Akne ist eine weit verbreitete Hauterkrankung. Über
den unterschiedlichen Behandlungserfolg diverser Tech-
niken (z.B. UV-Licht, gepulste Farbstofflaser, Dioden-
laser, LED, Radiofrequenzsysteme, intensiv gepulstes
Licht) wurde verschiedentlich berichtet. Bislang wurde
gepulstes Licht (hochenergetische Blitzlampen) entweder
allein oder in Kombination mit anderen Verfahren
eingesetzt, um eine schnelle Hautverbesserung bei Akne
zu erreichen.
Die photopneumatische Therapie ist eine neue Thera-
pieform, die eine Unterdruckeinheit zur Ansaugung
der Haut und eine gepulste Lichtquelle kombiniert, um
die optischen Eigenschaften der Haut günstig zu
verändern. Durch den Unterdruck wird vor der
Bestrahlung der Abstand zwischen den behandlungsbe-
dürftigen Bereichen der Dermis und der Hautoberfläche
reduziert, wodurch der verstopfte Talg aus den Talg-
drüsenfollikeln extrudiert werden kann. Die jüngsten
Studien zur photopneumatischen Therapie zeigen viel-
versprechende Ergebnisse bei der Behandlung der Akne
vulgaris.
Schlüsselwörter: Akne; Phototherapie; Hochenergetische Blitz-
lampen (IPL); Photopneumatische Therapie; Licht
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