How effective is Thermage in the treatment of moderate to severe acne?

Background: Acne vulgaris is a common skin problem that may not only cause scarring, but may also cause psychological stress and reduce people's self-confidence. While topical and internal medications are common treatments, some patients may experience treatment failure, experience side effects, or have contraindications to traditional treatments. To address these challenges, laser and energy device therapy has emerged as a promising alternative, showing great potential in acne treatment.

Objective: To evaluate the long-term efficacy and safety of nonablative monopolar radiofrequency (NMRF) in the treatment of moderate to severe acne.

Methods: The study was conducted in the dermatology department of a hospital in Thailand. 24 patients with moderate to severe acne received two NMRF treatments 4 weeks apart. To evaluate the treatment effect, patients' number of skin lesions, pore size and volume, and sebum secretion were quantitatively measured using the Antera® 3D Imaging System and Sebumeter®, respectively. Patients' self-assessment data on the degree of improvement and facial oiliness were also collected. The impact of AV on patients' quality of life was assessed through the Dermatology Life Quality Index (DLQI) questionnaire. All objective and subjective assessments were performed before treatment, 1 month after the first treatment, and at follow-up visits 1, 3, and 6 months after the last treatment. Adverse reactions were recorded at each follow-up visit.

Results: 20 of 24 participants completed the study protocol.

①The mean count of inflammatory lesions significantly decreased from baseline by 42.86% and 45.71% at 3 and 6 months after the second treatment.

②Sebum secretion was also significantly reduced from baseline by 11.62%, 13.37% and 21.51%, respectively, 1 month after the first treatment and 1 and 6 months after the second treatment.

③Pore volume continued to decrease by 35% and 41.5% at 1 month and 6 months after the last treatment.

④The DLQI index decreased significantly from 10.00 (interquartile range [IQR]: 6.50−15.00) to 2.00 (IQR: 1.00−4.75), equivalent to an 80% improvement in the index 1 month after the last treatment occurred and lasted until the last follow-up visit.

Patients' self-assessments of improvement and facial oiliness also improved significantly. The treatment was well tolerated with no significant adverse effects.

Conclusion: Non-ablative monopolar radiofrequency (NMRF) is effective and safe in the treatment of inflammatory acne vulgaris, and the therapeutic effect lasts up to 6 months after two treatments.

Significant challenges remain for the standardized management of acne vulgaris. Traditional treatments include topical and internal medications, as well as physical therapy. Due to the complex etiology and diverse clinical manifestations of acne, treatment often requires a combination of approaches. Acne treatment also needs to be personalized based on the severity of the condition and the patient's individual characteristics.

Among the many treatments, oral isotretinoin (Isotretinoin) is considered the most effective, targeting the four main causes of acne. This powerful medication is often used to treat moderate to severe acne, especially those with difficult-to-treat cases and those with severe physical and psychological scarring. However, the use of isotretinoin has raised concerns due to its possible side effects, such as mucosal dryness, potential teratogenic risks during pregnancy, and the need for long-term use. Some patients find it difficult to adhere to treatment, and some even refuse to take it.

With a deeper understanding of the pathogenesis of acne, energy source devices are beginning to be used in acne treatment. These devices are used not only to improve the sequelae of acne, such as hyperpigmentation and scarring, but also to target its causes, such as colonization by Propionibacterium acnes, inflammation, and sebaceous gland activity.

The main researcher of this article noticed in clinical practice that non-ablative monopolar radiofrequency (NMRF) also showed therapeutic effects on acne while performing facial skin tightening treatment. These benefits include reduction of inflammatory acne lesions and reduction of skin oiliness. Studies have also confirmed that NMRF treatment can reduce sebum secretion and skin oiliness. These results are related to the working principle of NMRF, which is to inhibit sebum secretion by volumetric heating of sebaceous glands.

Previously, there have been few studies on non-ablative monopolar radiofrequency (NMRF) for the treatment of acne, with only one case study conducted in 2003. The study's methodology lacked standardization, with some patients using both topical and oral medications and the number of treatments varying; moreover, the assessment relied solely on counts of active lesions, lacking objective assessment. Therefore, the purpose of this study was to objectively and subjectively investigate the long-term efficacy and safety of nonablative monopolar radiofrequency for the treatment of acne.

Equipment and Treatment.

This study was conducted at the Department of Dermatology, Siriraj Hospital, Mahidol University College of Medicine, Bangkok, Thailand, and involved 24 patients who received two non-ablative monopolar radiofrequency (NMRF) treatments 4 weeks apart.

Each patient received two consecutive nonablative monopolar radiofrequency (NMRF) treatments 4 weeks apart (equipment: Thermage FLX/Solta Medical).

Monopolar radiofrequency therapy uses a 4.0 cm2 probe and is delivered through the coupling fluid in a single pulse, non-overlapping manner. Treatment intensity varied from 2.0 to 3.0, with all participants initially starting at a treatment level of 2.5. Pain intensity was rated from 0 to 4, adjusted for each subject's self-reported moderate (level 2-2.5) pain threshold (0 means no feeling, 1 means warm, 2 means hot, 3 means very hot, 4 means very hot Indicates unbearable pain). The higher the treatment level, the greater the energy output of the device.

Uses low energy pulse multiple passes to improve effectiveness, tolerability and safety. Treatment pulses are applied sequentially (without overlap), ensuring adequate cooling intervals between passes to reduce epidermal damage. Two passes are performed on the entire face, with an additional two to four passes targeting areas of inflammatory and non-inflammatory acne lesions, with the goal of reaching the clinical endpoint of dark red appearance of inflammatory lesions (Figure 1).

Figure 1, Female.
(A) Before treatment, (B) Immediately after nonablative monopolar radiofrequency treatment: inflammatory lesions significantly transformed from moderate to deep erythema.

The number of pulses applied per treatment depends on the severity of the acne; the more numerous or widespread the lesions, the higher the number of pulses required. It is worth noting that this approach differs from the standard parameters of skin tightening treatments. In the skin tightening treatment, pulses first cover the entire face and neck, followed by 5-6 contour treatments to achieve the clinical endpoint of visible or tactile tightening.

After treatment, the patient is instructed to avoid the use of any anti-inflammatory drugs, including nonsteroidal anti-inflammatory drugs or systemic corticosteroids, for 1 week. Additionally, throughout the study period, patients did not use oral or topical medications that were excluded by study regulations.

Discuss

1.The pathophysiology of acne is complex and multifactorial and represents one of the major challenges facing dermatology. Developing an effective treatment plan requires a highly personalized approach that considers each patient's acne type and severity.

2.Energy source devices serve as an alternative to traditional treatments, especially for patients who are resistant to traditional treatments or who wish to avoid potential side effects.

3.The non-ablative monopolar radiofrequency (NMRF) used in this study is primarily used to improve skin aging rather than as a standard acne treatment. However, this study found that acne inflammation counts were significantly reduced after NMRF treatment, and the improvement was sustained up to 6 months.

4.This study did not include a histological evaluation of the effects of NMRF treatment, and the investigators attributed clinical improvements to NMRF's suppression of sebaceous gland activity through intradermal volumetric heating.

5.As the selective absorption wavelength of sebaceous glands, 1726 nm has been used in acne treatment and deserves attention.

6.This study found that patients' quality of life index significantly improved after NMRF treatment, and the improvement lasted to 3-month and 6-month follow-up.

7.NMRF treatment not only reduced acne lesions and facial oil, but also significantly reduced pore size.

8.Although NMRF treatment was well tolerated, studies observed transient self-limiting acne outbreaks (2-3 weeks after treatment) similar to isotretinoin, followed by a subsequent reduction in the number of acne lesions and a more rapid response to NMRF treatment.

9.This study is the first to comprehensively evaluate the efficacy of NMRF in the treatment of acne, including objective and subjective assessments. The study had limitations, such as a small sample size, lack of a control group, and the racial and gender distribution of the subjects that may have affected the results.

10.Recommendations for future research: Conduct histopathological analysis of skin after NMRF treatment to strengthen the correlation; extend the follow-up time to confirm the cost-effectiveness of NMRF as the preferred treatment modality.