INTRODUCTION

Acne vulgaris is a common inflammatory skin disorder that affects nearly 85% of adolescents and young adults. It has a multitude of factors contributing to its pathogenesis such as pilosebaceous duct hyperkeratinization, ductal colonization with Propionibacterium acnes (P. acnes), increased sebum production, hormonal factors, and diet. Furthermore, there has recently been an increased emphasis on the role of chronic inflammation and inflammatory cytokine cascades in the pathogenesis of acne.[1]

Topical and oral antibiotics, topical keratolytic, hormonal agents, and topical and oral retinoids are among the traditional treatments for acne vulgaris.[2] Alternative therapies have emerged due to increased resistance to traditional treatment options, as well as undesirable side effects. Many laser and light-based acne treatment devices have shown promising results and have paved way for a new modality for treatment of acne.[3] The precise mechanism of action of these devices in the treatment of acne is unknown, but it is most likely due to the generation of photothermal and/or photochemical reactions, which have a positive impact on the pilosebaceous unit and its influencing factors.[4]

Carbon peel laser technique or “Hollywood peel” (the popular Internet term) has been trending on social media as the latest technology in cosmetology for management of oily skin, uneven skin tone, facial wrinkles, and acne vulgaris. This technique works on the principle of skin penetration of an applied carbon solution into the pilosebaceous unit and this acts as an external chromophore for the absorption of laser energy as shown in Figure 1. The long pulse mode of laser energy initially exposed to skin acts in heating up the carbon particles. Subsequently, the quasi mode pulse creates thermal energy which causes the therapeutic effect. The thermal effect is put into use in causing destruction of the organism Propionibacterium acnes and also atrophy of sebaceous glands causing decreased sebum production for treating acne. The technique can also be used in managing photo ageing and facial wrinkles by stimulating collagen synthesis. This laser modality is also food and drug administration approved for management of melasma by causing selective destruction of melanocytes which contain melanin that acts as a chromophore. However not much scientific literature is available regarding the efficacy of this method in managing acne vulgaris and its advantage in cases not responding to topical/systemic therapy with potential side effects. The aim of this study is to evaluate the efficacy and safety of the “carbon peel laser technique” in the management of acne vulgaris in skin of color.

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Figure 1

Diagrammatic representation of the mechanism of action of carbon peel

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MATERIALS AND METHODS

A prospective randomized control trial was carried out during the period of October 2021 to April 2022. The subjects were recruited from the patients of acne vulgaris attending the outpatient department of our dermatology department. The study protocol was approved by the Research Ethical Committee of our center and all participants in the study were explained about the procedure and written informed consent was taken for the same.

RESULTS

All data were collected, tabulated, and analyzed using SPSS version 20.0 (IBM SPSS Statistics for windows, version 20.0. Armonk, NY: IBM Corp) and Microsoft Excel 365. A P-value <0.05 was considered as statistically significant. A total of 35 patients were studied, out of which 21 were women and 14 were men. They belonged to the age group of 18–35 years with mean age of 26.5 years. Out of 35 subjects, the following were the numbers in each grade of acne vulgaris: 11 (Grade IV), 23 (Grade III), and 1 (Grade 2). The ISGA grade was assessed pre- and posttreatment. The postprocedure mean ISGA was 1.342 as compared with preprocedure mean ISGA of 3.657 with P-value <0.0001. Among the study population, 28 (80%) showed >80% improvement and 7 (20%) showed 50%–80% improvement in skin lesions in the form of decrease in the number, size of lesions, and extent of inflammation as shown in Figures 2 and 3. It was noticed that none of the patients were nonresponsive to this treatment technique. The postprocedure complications were minimal; however, out of total 35, 6 (20%) developed erythema, 1 (3.3%) developed mild tolerable pain, and none developed postinflammatory hyper/hypopigmentation. Since the P-value of the comparison between ISGA pre- and posttreatment was less than 0.05 (<0.0001), which is significant, it is inferred that carbon peel laser technique is definitely a very effective modality for management of acne vulgaris in patients with skin of color with negligible side effects.

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Figure 2

Gender wise distribution of the improvement results

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Figure 3

Serial improvement in the patients with the before and after 2 weeks photographs for comparison

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DISCUSSION

Acne vulgaris is one of the most common dermatologic diseases, affecting both teenagers and adults and having the potential to have long-term psychosocial and physical consequences.[5] Being a chronic inflammatory skin disorder, a long-term combination treatment as well as maintenance therapy is recommended for management of acne vulgaris. Traditional treatments, such as topical and oral medications, are frequently associated with poor adherence, a lack of long-term remission, and potential side effects. The complications of acne if left untreated are scarring, dyspigmentation, and physical discomfort. So prompt and safe treatment modality is the key to the management of this condition.[6]

Carbon peel laser technique was conceptualized in 1997 by Goldberg et al. for laser hair removal. After giving promising results due to its effect on hair follicles, the technique has extended horizons in treating acne vulgaris and minimizing skin pores.[7] This technique is popularly known as “Hollywood peel” due to its use as a leading anti-ageing treatment in Los Angeles by celebrities. Although the Q-switched 1064-nm Nd:YAG laser is not commonly used for acne treatment, careful manipulation of the beam parameters or combination with an exogenous artificial chromophore, such as topical carbon gel acting as a photo enhancer, has been linked to significant improvements in acne. This effect could be attributed to thermal influence of laser energy on the pilo-sebaceous unit and P. acnes, as well as a decreased cytokine-mediated inflammatory cascade, which is the key player in acne pathogenesis.[78] This technique has added advantage of causing neo-collagenesis resulting in improvement of skin texture and acne scar remodeling. Interestingly, the carbon peel laser technique also provides a peeling effect, exfoliating the skin surface and plugged pores, thereby correcting follicular epithelial hyper-cornification that blocks the physiologic outflow of sebum to the skin surface and reduces skin inflammation.[8] This technique has its perks of being absolutely painless, “lunch break procedure” with zero downtime. So it is preferable compared with the long-term systemic treatment for severe acne which comes with its own gamut of side effects. In our study, significant reduction of erythematous and nodular acne lesions was noted after two sittings of carbon peel laser technique 2 weeks apart. There were no serious side effects reported in our study. Among 35 study subjects, 6 (20%) developed erythema, 1 (3.3%) developed mild tolerable pain, and none developed postinflammatory hyper/hypopigmentation (which is a common side effect encountered in Asian skin). Although a lot of information is available on carbon peel laser technique in social media, we found that there is no scientific literature available regarding its efficacy on population with skin of color. Since the side effect profile of laser therapy also varies depending on ethnicity of skin, we felt it necessary to study the effect of this technique on Indian skin. The patients had showed marked improvement in acne with only this modality without any adjuvant topical/systemic therapy which makes the study unique.

CONCLUSION

Carbon peel laser technique is definitely a very effective treatment modality in management of acne vulgaris, which is severe and is nonresponsive to conventional treatment modalities. This technique can be used as a single tool for management of inflammatory acne. The technique has the benefit of not causing any postinflammatory hyper/hypopigmentation in the patients which is a very common adverse effect noticed in other surgical modalities for acne management (e.g., microneedling and dermabrasion). It is an ideal choice for young adults who are not willing to opt for long-term systemic therapy and expecting quick results. However, there is a requirement of further research with a larger sample size for validating the benefits for this technique and study the long-term follow-up results.