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Acne treatment: the utility of azelaic acid, and photopneumatic technology

This article will address two recently published reports on acne treatment.

The 4 problematic components of acne are: 1) increased production of sebum (skin oil); 2) follicular hyperkeratosis (overgrowth of horny tissue); 3) proliferation of Propionibacterium acnes (P. acnes), a bacterial species that infects skin; and 4) reactive inflammation.

Azelaic acid for treating acne

Here is the abstract for the study on azelaic acid–(1, zip)

Azelaic acid (AzA) 15% gel is approved for the treatment of rosacea in the US, but also has approval for the treatment of acne vulgaris in many European countries where it has demonstrated success. Two randomized, multicenter, controlled clinical trials compared the effects of AzA 15% gel with those of topical benzoyl peroxide 5% or topical clindamycin 1%, all using a twice-daily dosing regimen. The primary endpoint in the intent-to-treat analysis was a reduction in inflammatory papules and pustules. AzA 15% gel resulted in a 70% to 71% median reduction of facial papules and pustules compared with a 77% reduction with benzoyl peroxide 5% gel and a 63% reduction with clindamycin. AzA 15% gel was well-tolerated. In addition, a 1-year European observational study conducted by dermatologists in private practice evaluated the safety and efficacy of AzA 15% gel used as monotherapy or in combination with other agents in more than 1,200 patients with acne. Most physicians (81.9%) described an improvement in patients' symptoms after an average of 34.6 days, and 93.9% of physicians reported patient improvement after an average of 73.1 days. Both physicians and patients assessed AzA 15% gel to be effective with 74% of patients being "very satisfied" at the end of therapy. AzA 15% gel was considered "well-tolerated" or "very well-tolerated" by 95.7% of patients. The majority of patients were more satisfied with AzA than with previous therapies. AzA 15% gel represents a new therapeutic option for the treatment of acne vulgaris.

So what is the good news about azelaic acid?  From the report–

It is well-tolerated by itself or in combination with other agents.  It has a clinical profile that is compatible with long-term use, including sustained efficacy, the inability of bacteria to become resistant to it and patient acceptance.  It is not teratogenic (tending to cause birth defects) or mutagenic (tending to alter the genetic code), and consequently can be used safely during pregnancy.  So azelaic acid is a good choice to treat papulopustular acne vulgaris.

Photopneumatic technology for treating acne

People have successfully used light sources to combat, to some extent, mild to moderate acne.  Blue light kills the bacteria that infect acne-laden skin and red light reduces inflammation.  The light sources can be bulbs or light-emitting diodes emitting a narrow range of colors or a laser emitting a single frequency light. 

Here is a basic review of the traditional light-based treatments–

Blue light exposure. Blue light is used to target the bacteria, but this is of limited help for dark-skinned people or people in whom there is a lot of blood flowing close to the skin surface since melanin (brown pigment) and hemoglobin (red pigment) will absorb a lot of the light.  To make the light penetrate farther, one has to use higher energy lasers, which makes the treatment painful, necessitating the use of anesthetics.  

Pulsed light and heat treatment. This combines pulses of light with heat.  The light targets the bacteria and the heat targets the sebaceous glands (oil-producing glands in skin), shrinking them, but there is a risk of heat-related damage to surrounding tissue.

Photodynamic treatment. 5-aminolevulinic acid or methyl aminolevulinate is applied to the skin for 15 – 60 minutes to make the skin more sensitive to light.  Then the skin is cleaned and exposed to blue or red light.  Side effects include temporary reddening, skin swelling, increased pigmentation of skin and sometimes vesiculation (the papules start becoming vesicular or like a vesicle).

These approaches have been recommended for mild to moderate acne.  The most effective treatment has been a combination of pulsed light plus heat treatment and photodynamic treatment.  Now a more effective light-based technology employing a photopneumatic (light + suction pressure) device has been approved for treating mild to moderate acne as well as pustular and comedonal acne.  A study has shown that it improves even severe nodular acne and severe cystic acne.(2, pdf)  And the good news is that no anesthesia is required since the process is not painful.

Basically, this device is put on the skin and sucks some of it in, and then the oily contents are mechanically removed.  The surface of the sucked-in skin expands, better allowing light to penetrate it.  Blue light destroys the bacteria and red light reduces inflammation.

Pictures say it–

Before and after treatment of acne by a photopneumatic device.

Fig 1. After 2 treatments, spaced 9 weeks apart.

Before and after treatment of acne by a photopneumatic device.

Fig 2. After 3 treatments.

Before and after treatment of acne by a photopneumatic device.

Fig 3. After 4 treatments.

Before and after treatment of acne by a photopneumatic device.

Fig 4. After 4 treatments.


  1. Thiboutot, D., Versatility of azelaic acid 15% gel in treatment of inflammatory acne vulgaris, J Drugs Dermatol, 7, 13 (2008).
  2. Shamban, A. T., Enokibori, M., Narurkar, V., and Wilson, D., Photopneumatic technology for the treatment of acne vulgaris, J Drugs Dermatol, 7, 139 (2008).


People really need to change their diets in order to combat acne, especially the severe forms of acne as pictured above.

Whereas diet may worsen or improve acne to a small extent, it is not the primary cause of acne.

As a Rosacea sufferer, I can tell you that the condition is 100% systemic. You cannot treat it with only topical medications. Many times you see studies done where they "prove" that the new topical helps rosacea, but they always combine it with oral antibiotics. The antibiotics are what help the rosacea, end of story. They do not reduce bacteria, but inhibit the synthesis of certain proteins in the skin, reducing the flushing and swelling that causes Rosacea.

Diet is a HUGE component of Rosacea. Caffeine is the #1 problem with most sufferers. Remove caffeine from your diet and the condition improves dramatically. Also many food additives in meats and dairy are very bad for the skin. One interesting side effect of vegetarianism is acne rosacea disappears, assuming you stay away from large amounts of cheeses.

I've tried azelaic acid, laser therapy, topicals, sulfur, and many others and none have had the effect of diet and antibiotic therapy.

Rick: The studies don’t mention a definitive cure for acne. They document treatments that help improve acne, to varying degrees depending on the individual, and given their relative lack of side effects and cost effectiveness, afflicted individuals would generally be well-advised to try them out.

The study using azelaic acid cites the effectiveness of the drug when it is used alone, not in combination with antibiotics, though antibiotics could be added if needed.

now that's cool! :)
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