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Whether you experience the odd breakout or regular flare-ups, take back control of your complexion by reducing the appearance of acne and skin breakouts with a Dermapen Treatment™.Problematic skin is often the result of overly active oil (sebaceous) glands and imbalanced hormones.The excess oil (sebum) gets trapped in your pores along with dead skin cells and debris, which can lead to painful inflammation and leave your skin prone to other bacteria proliferation.Central to your Dermapen Treatment for acne is a clinical procedure with a Dermapen 4™ device.
The 16-needle cartridge glides over the skin, creating up to 1,920 fractional micro-channels per second. Due to the microfine needles, incredible speed, and quality seals, a clinical procedure with the Dermapen 4 is virtually pain-free and finished in no-time.
The professional device penetrates the deeper layers of the skin, triggering the body’s natural healing response. The skin is oxygenated and lymphatic drainage activated, regenerating the acne-affected area.The final result is improved appearance of problematic skin breakouts, black/whiteheads (comedones), acne and scarring.

Acne is a common skin condition that arises from pilosebaceous unit dysfunction, which consists of a hair follicle and its associated sebaceous gland. Acne affects approximately 85% of individuals between the ages of 12 to 24 years. Typically, it first manifests at puberty, when increasing androgen levels activate the sebaceous glands, which begin producing sebum.
As androgen levels continue to rise, sebaceous glands become hypertrophic, and the amount of sebum greatly increases.
Sebum is a powerful inflammatory agent that leads to the more severe forms of acne and scarring when produced in excess. Sebum also disturbs the maturation of keratinocytes (dyskeratosis) by inducing epidermal inflammation. These two factors—increased sebum production and the dyskeratotic keratinocytes—cause occlusion of pores and the subsequent appearance of whiteheads. When the trapped material in the pores oxidizes and turns dark, whiteheads appear as blackheads. Blackheads are commonly seen in areas with enlarged pores, such as the nose. The immune system’s response to the excessive sebum on the skin surface, together with the trapped sebum in the hair follicle and the bacterial flora (Propionibacterium acnes), leads to the appearance of inflammatory cystic lesions that involve the dermis and lead to acne scars. The severity of inflammation leads to the spread of acne lesions and the formation of pustules, inflammatory nodules, and more cysts.
Inflammation induced by the presence of increased sebum and P. acnes leads to variable degrees of scarring and postinflammatory hyperpigmentation (PIH) in certain patients. Over time, the chronic inflammation with its destructive effects damages skin texture, producing rolling, boxcar, and ice-pick scarring. Occasionally, hypertrophic scars and keloids can appear in predisposed individuals with severe acne.

Factors Contributing to Acne Development and Severity
■ Heredity: the size, number or density, sensitivity, and activity level of sebaceous glands
■ Disorders of keratinization, in which corneocytes are not shed at an adequate rate. This can cause occlusion of pores and microcomedone formation.
■ Lifestyle, including exposure to:
Practices that increase sebum production (e.g., hot showers or baths, saunas or steam rooms, and sweating from physical exertion or warm climates)
Dietary factors (nonorganic dairy products from cows that have been given hormones, a diet with a high glycemic index [which induces inflammation], and stimulants, such as caffeine)
Inappropriate skin care products (moisturizers, which weaken skin, and oil-based makeup)
■ Hormonal factors: systemic hormonal abnormalities (e.g., polycystic ovarian syndrome and other conditions associated with excessive androgens).
Additionally, hormonal changes before and during a woman’s monthly menses, as well as those that occur during pregnancy, may cause acne to develop or flare.
Patient manipulation of acne lesions: attempts to squeeze or extract whiteheads or cysts can increase lesion depth, inflammation, and the immune response, creating more aggravated acne flare and increasing the potential for postinflammatory hyperpigmentation

The range of topical and oral acne treatment options currently on the market is so broad that it may seem limitless. Similarly, recommendations on how to use specific products (alone or in combination) are numerous.
The approach presented here is based on several fundamental beliefs that may contradict what many physicians accept as standard in acne treatment.
One such belief, which lays the foundation for the treatment protocols in this chapter, is that acne is preventable. 

Acne is preventable only if addressed at the initial stages, when whiteheads and blackheads begin to appear, but before sebum-induced inflammation can trigger the immune response. Every effort should be made to eliminate whiteheads and blackheads in the early, noninflammatory acne lesions stage.
In actuality, sebum and the resulting inflammation are the main problems in acne, and the control of sebum may be the key to acne prevention and treatment

Acne treatment should represent only a portion of the broader approach that aims to restore general skin health. Healthy skin is less susceptible to acne. Accordingly, the treatment objective should be not only to temporarily slow down sebaceous gland activity and dry up the pimples but also to restore skin health while correcting all of the contributing factors responsible for causing acne at the same time.
As such, the first consultation should include a thorough patient history and a physical examination.
If an underlying systemic hormonal abnormality is suspected as contributing to the patient’s acne, the patient should have appropriate blood tests ordered during the visit; a consult with an endocrinologist may also be appropriate in this setting. In female teenagers, it appears that certain birth control pills can help tremendously to regulate hormonal factors that play a major role in their acne condition. Such pills include drosperinone (Yaz), which counteracts the androgens that drive sebum production. Additionally, other agents such as spironolactone or insulin resistance agents (e.g., metformin) can be used. The physician must also determine whether a systemic antibiotic or isotretinoin is indicated. In short, the physician must determine the acne type (comedogenic [cystic and nonscarring] or severe [cystic and scarring]) and, based on the type, inform the patient (Box 6.3) and discuss treatment options. Patient 
compliance with a daily treatment regimen is essential, while at the same time improving overall skin health, includes the following: skin preparation, addition of disease-specific agents (if indicated), exfoliation and stimulation of epidermal renewal, barrier repair, stimulation of the dermis (for deep repair), hydration and calming (only if needed for skin dryness), and sun protection.
 Treatment should begin with appropriate topical agents; systemic agents can be added when needed.
Procedures such as exfoliative peels and photodynamic therapy (PDT), with blue or red light, can be used to assist treatment, but never as the first line of treatment. For example, if PDT is going to be used, one should start with all essential and supportive topical agents (see Chapter 3).
When the acne is somewhat controlled and the skin is more tolerant (e.g., after at least 6 weeks on a topical regimen containing essential topical agents), PDT sessions can be added to the overall treatment plan to accelerate and improve results. The topical photosensitizing agent applied before PDT treatment collects preferentially in sebaceous glands, and the subsequent exposure to light of the appropriate wavelength destroys those glands

Along with the discussion and planning that occurs at a patient’s first visit, the skin therapist can take certain steps to resolve some of the patient’s most pressing acne issues during that same visit.
These include extraction of comedones, intralesional steroid injection into inflammatory acneiform nodules, and initiation of a short course of oral steroids .
Furthermore, to help unclog pores and dry cystic lesions faster, skin therapists can use exfoliative procedures or products, including alpha-hydroxy acids (AHAs), beta-hydroxy acids (BHAs), or exfoliative chemical peels (Invisapeel, Non-irritating Ossential Exfoliating Polish once daily, Ossential Advanced Radical Night Repair, ZO 3-Step Peel) after the first maturation cycle of treatment (6 weeks) has been completed.

Dr. Zein Obagi’s Revised Acne Classification Current acne classifications (mild, recalcitrant, severe; comedogenic, cystic adult acne—conglobata, necrotica, keloidae) are merely descriptive terms that Early Acne Interventions (during Initial Visits)
■ Extraction of individual comedones
■ Injection of active inflammatory acneiform nodules and cysts (to stop inflammation and prevent scarring)
■ Initiation of a 1-week course of oral systemic steroids (if not contraindicated) in patients with severe cystic acne that involves the face, back, or chest
■ Methylprednisolone in tapered doses (60-50-40-30-20-10-5 mg/day), which can be helpful in severe cases
■ If needed to arrest inflammation (while the patient is also starting on oral isotretinoin): repeated additional courses of oral systemic steroids (1 week per month for two to three courses) until isotretinoin benefits become apparent
■ If systemic steroids are contraindicated, an alternate anti-inflammatory agent, such as 200 mg ibuprofen daily for 10 days, repeated once a month during the first three keratin maturation cycles (18 weeks) of treatment Box 6.5 146

Skin Health Restoration and Treatment in Acne Patients
1. Skin preparation:
■ Washing face twice daily with a cleanser specifically formulated for oily skin
■ exfoliation
■ Application of a sebum-reducing astringent

2. Addition of disease-specific agents
■ Examples include topical benzoyl peroxide, antibiotics, dapsone, adapalene, tazarotene
3. Epidermal renewal—alternate daily with the disease-specific agents
■ Exfoliation: all patients should use topical alpha-hydroxy acids
■ Postinflammatory hyperpigmentation, if present:  non-HQ agents can be added
4. Barrier repair agents (for epidermal stabilization), AM 5. Stimulation of the skin (for deep repair), PM
■ Tretinoin (retinoic acid)
6. Hydration and calming of the skin (as needed, to reduce reactions and improve compliance) (optional)
7. Protection of the skin—sunscreen daily, nonoily makeup

Treatment Duration and Phases in Acne Treatment
Treatment duration: three keratinocyte maturation cycles (KMCs), which are 6 weeks each (18 weeks total),
in which each cycle represents a treatment phase.
These include the following:
1. Repair phase: expected skin reaction to topical medications
2. Tolerance phase: reactions begin to subside; skin improvement starts to become noticeable
3. Completion phase: minimal to no skin reactions persist, and maximal improvements are seen
Every patient should follow a maintenance program after completion of active treatment to prevent recurrence

systemic treatment.
Similarly, patients presenting with cystic acne and subsequent active scarring may require concurrent systemic treatments such as oral antibiotics, isotretinoin, spironolactone, or other agents.
If acne improvement after one keratin maturation cycle (KMC) (6 weeks) is minimal and new lesions continue to appear despite patient compliance with a thorough topical regimen, the physician has two options:
• Add antibiotics for 1 to 2 months (if acne scars are not present), with the plan to wean the patient off the antibiotics as soon as improvement is achieved.
• Add isotretinoin (especially if acne scarring is actively occurring). Role of Antibiotics Many physicians prescribe topical and/or oral antibiotics for acne, using the rationale that these agents will kill P. acnes and other potential strains of bacteria and reduce inflammation.
However, such an approach introduces concerns that likely outweigh these treatments’ merits. In particular, research shows that patients using topical or systemic antibiotics for acne should use them in pulsed fashion to reduce the potential for the development of antibiotic resistance. Specifically, after a patient has used one antibiotic agent for 2 or 3 months, he or she should be switched to another agent. Additionally, oral antibiotics have the potential for many side effects. These include, but are not limited to, bacterial resistance, gastrointestinal upset, photosensitivity, allergic reactions (including anaphylaxis), and, rarely, severe cutaneous immune system reactions, such as Stevens-Johnson syndrome.
For these reasons, the physician should limit acne treatment with systemic antibiotics to 2- to 3-month intervals and repeat only when necessary. Overall, the benefits of systemic antibiotics in acne are likely overstated.
Antibiotic Treatment of Acne
■ Systemic antibiotics are not essential in acne treatment.
■ If systemic antibiotics are used, they should be administered in 2- to 3-month “pulses,” followed by rest and subsequent treatment with a different antibiotic, if necessary.
■ This applies only in cases in which the acne is responding well to the systemic antibiotics and no postinflammatory scarring is appearing

Role of Oral Isotretinoin Isotretinoin is extremely effective in the treatment of acne because it addresses the role of sebum. Namely, isotretinoin reduces sebum production that then decreases inflammation, lowers P. acnes counts, and inhibits microcomedone formation. According to the U.S. Food and Drug Administration (FDA), it is indicated for patients who have severe, inflammatory, recalcitrant nodular or cystic acne. In 2006, the FDA implemented the iPLEDGE Program, which manages potential risks of isotretinoin use by educating patients in an attempt to eliminate fetal exposures to this highly teratogenic drug. Accordingly, it cannot be given to women who are breastfeeding, pregnant, or planning a pregnancy in the upcoming 6 months or so (assuming a 5-month treatment course with isotretinoin). Isotretinoin also has been associated with increased risk for developing or worsening depression (including suicidal ideation).
The association between isotretinoin use and an increased risk for inflammatory bowel disease has not been completely elucidated, but evidence for an association does not appear to be strong. Other potential contraindications include hepatic dysfunction (isotretinoin is metabolized in the liver), severe hyperlipidemia (isotretinoin can lead to a slight elevation in cholesterol), anorexia nervosa, and osteoporosis.
If isotretinoin is contraindicated or the patient declines the drug after a thorough discussion of its risks and benefits, the physician may prescribe a series of treatments with photodynamic therapy.
Guidelines Regarding Isotretinoin
During the past decade, the reputation of isotretinoin has been tarnished, particularly in the popular press, as lawsuits over potential and purported side effects have garnered headlines by targeting prescribers and manufacturers of isotretinoin. These developments have created a fear of isotretinoin that the public and many physicians now share. Many patients, even those with severe, recalcitrant, scarring acne, refuse to consider the drug because they have researched it online and have come across various sources claiming harmful effects from the medication.
Many of these concerns appear to be exaggerated. To date, isotretinoin has usually been prescribed for patients with severe nodulocystic acne that resists traditional treatments such as topical agents, as well as systemic antibiotics and hormonal therapies.



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