Acne can form on your face when skin pores get clogged. Apart from making one feel insecure, acne can also be painful and leave stubborn scars and redness behind during the healing process. In this article, we will discuss the causes of acne scars and all you need to know about fractional CO2 laser for acne scars treatment.
What causes acne and how do acne scars form?
Acne is a common disease that prevails in 90% of adolescents, and has the ability to persist to adulthood with psychological and social implications. Acne typically appears when hair follicle openings become blocked by over-secretion of oil and dead skin or bacteria accumulation in the pores. Acne scars, on the other hand, result from the inflammation of acne blemishes. In some cases, the contents of the blemishes spill into surrounding tissue that may cause deeper scars. They take on 2 main forms, either the scar develops when there is a loss of tissue, or when it is raised above the skin surface. They include:
Located at areas with thicker skin, usually on the lower cheeks and jaw. Atrophic scars are further classified into ice pick, rolling and boxcar type. Ice pick indents are observed to have narrow and deep scars. Rolling scars are wider and can reach to the subcutaneous adipose (fat) tissue. Lastly, boxcar types have visible vertical edges which are wider than ice picks.
These lesions of scar tissue that rise off the surface of the skin are caused when collagen in that region is overproduced. They are usually located on the chest, shoulders and jawlines. Additionally, they tend to be itchy or painful.
CO2 Laser for acne scars
Laser treatments aim to minimize the scar appearance from acne outbreaks. It focuses light on the skin surface to disrupt the scar tissue while also encouraging new, healthy skin cells to grow and replace the scar tissue. One such type is the fractional carbon dioxide laser method.
What does fractional CO2 laser do?
The CO2 laser is a non-invasive skin treatment that uses a laser made of CO2 to remove the outer layers of damaged skin and hence, acne scars. This particular laser system is the gold standard in acne scar treatment whereby it obtains better results with minimal thermal damage to the skin and also keeps the epidermis intact. Benefits of this method compared to other lasers include less tissue damage and edema, as well as faster recovery.
How is the CO2 laser procedure done?
The CO2 laser for acne scars is an ablative procedure, meaning it operates by breaking up the skin. The laser with a wavelength of 10,600nm penetrates deep into the skin. The epidermis (thin outer layer of the skin) is removed and dermis (underlying skin) is heated. This will then stimulate the body’s natural healing process and boost collagen fibre production, which ultimately results in the replacement of old, damaged cells. After the epidermis regrows, the treated skin will appear clearer, smoother and tighter.
Who should avoid CO2 laser for acne scars?
Generally, it is advisable for patients suffering from extensive breakouts, open wounds or facial infections to avoid the fractional CO2 laser for acne scars. It’s also worth noting complication preventions throughout the treatment process. Patients prone to poor wound healing or hypertrophic scarring should avoid aggressive skin resurfacing.
How long does CO2 laser resurfacing take to heal? Is there any downtime?
The period of recovery heavily depends on the severity of the condition, but the use of fractional technology has enabled healthy tissues to produce cells and proteins that will quickly aid in skin healing. Therefore, patients only have to undergo shorter recovery periods that last around 5 to 7 days.
Is the CO2 laser for acne scars painful?
The treatment is usually done with anesthesia so as to minimise any occurrences of discomfort. Most patients describe it as only a prickling sensation. The different types include topical anesthesia and numbing cream. Otherwise, painkillers and anti-itching medications may also be administered.
How many CO2 laser treatments are needed?
The number of treatments for CO2 laser for acne scars mainly depends on the severity of the condition and the extent of the acne scars. Typically, patients undergo 1 to 3 sessions on average, which can be carried out at 4 to 6 weekly intervals.
Side effects of CO2 laser for acne scars
Since the fractional CO2 laser procedure encompasses heat, patients may experience redness or swelling in the treated area. In rare cases, studies show that the adverse side effects of laser methods include bacterial, fungal or herpetic infections, which are short-term. Long-term side effects may consist of prolonged erythema, post-inflammatory hyperpigmentation particularly in skin of color.
Adjunct Treatment for Acne Scars
While the fractional CO2 laser is a first-line treatment for acne scarring, the potential for side effects from long-term, continuous treatment is an issue. Research has found that additive or adjunct treatments such as those with cosmeceuticals and radiofrequency, can be effective in the treatment of acne scars.
Cosmeceuticals that include the botanical ingredient Centella Asiatica can be beneficial when it comes to anti scarring. This phytochemical has anti-inflammatory and wound healing properties for cysts, scars, and sensitive skin. Centella asiatica contains compounds like asiaticoside for increasing strength of the new skin at the wound, and madecassoside for collagen formation and anti-inflammation, especially helpful for treating acne scars.
THE ELIXIR-V™ TOTAL RECOVERY SERUM formulated with Centella Asiatica for scar healing, is an intensely nourishing concentrate of deep hydrating, lifting and tightening peptides for the perfect V-face look.
In one study Mu et al highlighted that combining radiofrequency energy with fractional CO2 has the effect of a temperature increase in the dermis, the deeper layer of the skin. This temperature increase produces a firming and compacting effect in the skin. One 10 patient study found that this method of radiofrequency and fractional CO2 combination showed more improvement and faster healing with fewer side effects of pigmentary changes in the treatment group.
Radiofrequency alone has shown efficacy in acne scar treatment. The mechanism of action of thiis technique also complements that of laser resurfacing in fractional CO2 lasers.
The CollagenUp Facial Wand is an FDA approved home radiofrequency device which increases absorption and helps in skin cleansing and moisturizing in addition to photofacial light functions. Use this radiofrequency device at home in conjunction with CO2 laser for better results in your acne scar treatment routine.
Petrov A, Pljakovska V. Fractional Carbon Dioxide Laser in Treatment of Acne Scars. Open access Macedonian journal of medical sciences. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4884248/. Published March 15, 2016. Accessed May 20, 2021.
Mu YZ, Jiang L, Yang H. The efficacy of fractional ablative carbon dioxide laser combined with other therapies in acne scars. Dermatol Ther. 2019;32(6):e13084. doi:10.1111/dth.13084
Acne in teenagers and adults is a troubling condition, affecting one’s self-esteem and confidence levels. In my clinical practice as a dermatologist, acne vulgaris, colloquially known also as pimples, forms at least 50% of the daily load of patients I see. There are many aspects to be addressed within the dermatology consultation.
This varies from the cause of pimples, to questions about effective acne treatments, DIY formulas, over the counter acne creams and prescription medications. I have sought to share as many of these treatment pearls in the following article as comprehensively as possible, and hope it can help shed some light on the best acne treatments available.
Dr. Teo Wan Lin is an accredited dermatologist and an expert on cosmeceutical skincare research and development. She is the author of “Skincare Bible – Dermatologist’s Tips for Cosmeceutical Skincare” which was published July 2019 by leading bookstores Barnes & Noble, Baker & Taylor and Apple Books and available in bookstores islandwide from January 2020. She is the founder of Dr.TWL Dermaceuticals, a specialist cosmeceutical skincare line with evidence-based active ingredients for anti-ageing and skin health. Dr. TWL Pharmacy is the only full fledged online specialist dermatologist compounding pharmacy in Singapore and is jointly headed by a trained pharmaceutical engineer for strict quality controls.
Why do pimples form and what exactly is happening to your skin when a pimple forms
Pimples is the colloquial term for Acne Vulgaris. This refers to an inflammatory condition of the skin that presents with blackheads and whiteheads, otherwise known as closed comedones and open comedones respectively, inflamed papules as well as acne cysts. The cause of Acne Vulgaris is multifactorial.
First of all, it is determined by one’s genetics. Individuals with a family history of acne tend to have a higher chance of developing acne. This is brought on by the onset of puberty which leads to the secretion of the male hormone, testosterone. Testosterone, in turn triggers oil production in both men and women. That being said, sebum, the oily substance secreted by your sebaceous glands, is essential for the entire process of acne formation.
The third thing that occurs due to one’s genetics, is the process of inflammation itself which leads to comedone formation. All pimples whether whiteheads or blackheads arise first as microcomedones under the surface of the skin.
When they reach the surface of the skin, they become visible. The process that drives this is a mix of genetics, the presence of sebum as well as some form of dysregulation of the process of follicular keratinisation i.e. the way your skin retains dead skin cells around your skin pores.
Aside from genetics, there is also the involvement of a bacterium known as Propionibacterium acnes – a heavy commencer in individuals who suffer from acne. Finally, a lot of acne flare-ups can be due to the secondary bacterial infection of existing acne bumps known as gram-negative folliculitis. This tends to present with pus-filled papules and tend to have a yellowish tip.
I have observed that I always get acne in the same spot
While I do hear this coming from my patients quite often, i.e. “I always get this one pimple now and then on my cheek, chin, forehead…”, there is no scientific answer to this. From my personal experience, this could be due to one of the following. Firstly, if you tend to pick at your pimples, there is a condition known as acné excoriée. The entire name of this condition in french is acné excoriée des jeunes filles meaning acne excoriée of young girls.
There is an element of this compulsive picking of acne and this is the main reason why I find my patients having acne at the same spot. They constantly pick at it so even when it is healing, it does not get the chance to heal and picking introduces secondary bacterial infection.
The second reason why is because you are suffering from some form of acne that is related to occlusion. Some people wear helmets or face masks. If acne develops around that area, it is a type of acne known as occlusion acne. It could also be due to the application of comedogenic, hair waxes etc.
The third thing, if you are talking specifically about acne on the chin, you have to consider perhaps it is not acne at all. There is a condition known as perioral dermatitis. Perioral dermatitis looks very similar to acne and if you are seeing a non-specialist, it is very easy to be confused. This is because the bumps look very similar to acne, except that it is a mixture of eczema and inflammation, acne bumps, or it could even be acne rosacea.
All about Acne Creams
When you apply a pimple-clearing product to your pimple, what happens to the spot? What are some of the ingredients that you’d want to look out for in a pimple product, and what should you avoid? Are pimple drying lotions ok for the skin and how do they work?
If you find yourself searching online for answers to these questions, you are not alone. These are some frequently asked questions by sufferers of acne and I shall seek to clarify them here. There are a few categories of pimple-clearing creams. The first being the good old-fashioned creams that simply dry out the skin and reduce sebum production.
Pimple Drying Medications
This category would include topicals that contain the following active ingredients: benzoyl peroxide, salicylic acid, calamine lotion, sulfur-containing lotions. In some mild cases these creams may lead to an improvement in acne itself.
Pimple Creams Containing Antibiotics
The second category of acne treatment creams would be those containing antibiotics. The commonest antibiotic-acne gels would be those which contain clindamycin or erythromycin as an active ingredient.
These work on the premise that a lot of cystic acne is caused by secondary bacterial inflammation. As with all topically applied antibiotics especially in a chronic skin condition like acne which is not primarily due to skin infection, there is a huge problem with using topical antibiotics.
Topical antibiotics work well in a short-term simply because the skin has never been exposed to it. But very quickly the body learns to identify the antibiotic and develops resistance.
This is particularly concerning because the resistance doesn’t just take place in the skin level. Exposure of the topical antibiotics on the skin level leads to resistance systemically as well. For example, it could lead to antibiotic resistance when one is older.
The main thing about antibiotics is that it is a mere short-term fix and does not work after some time. There are other combinations of antibiotic gels, such as clindamycin combined with benzoyl peroxide which is the active ingredient present in the OXY pimple cream. The benzoyl peroxide component has been proven to reduce the emergence of bacterial resistance.
Prevention Creams – Retinoids for Acne Treatment of Whiteheads and Blackheads
The third category of pimple creams which I consider more preventive rather than treatment sort of cream is the retinoid category. These are the vitamin A derivative creams. We have heard of creams like tretinoin and adapalene which may have differing trade names. Both these creams are Vitamin A derivatives and they work via preventing microcomedone formation.
However, when you apply these creams, you should not apply it to inflamed active pimples as this can worsen the inflammation process. Rather they should be used in conjunction with active acne treatments prescribed by a dermatologist which is proportionate to the severity of your acne as preventive treatment. When you start applying a retinoid cream for example, you only get to see the result 2-3 weeks later.
A Dermatologist’s Recommendation of the Ideal Pimple Cream – New Generation Anti-Inflammatory, Anti-Sebum Pimple Creams
The fourth category of acne treatment creams is actually what I actively advocate now and which we have formulated in a highly effective Blemish Spot Cream under Dr.TWL Dermaceuticals. It is targeted at reducing inflammation itself. I am very convinced that botanicals have a prominent role to play in cosmeceuticals.
Cosmeceuticals are no longer just confined to the realm of having anti-ageing properties but are also adjuncts for the treatment of many medical skin conditions. I have used botanicals extracts successfully in the treatment of rosacea for example.
For acne, I incorporate an algae extract from chlorella vulgaris which actively reduces the oil gland activity. This is combined with amino acids such as methionine and serine that help to heal the skin when you apply it. The main thing is that when you try to dry up an active pimple, very often you get more inflammation as you are burning the skin around it.
What you need to do is to try to get the pimple to heal as quickly as possible. This is so that you minimise the risk of scarring. At the same time, this also treats the underlying problem of acne pimples which keep forming.
Are there different pimple creams best suited for the different types of acne (eg blackheads whiteheads, red swollen pimples)?
For tretinoin and adapalene which are the two main available form of vitamin A creams, these should not be used for red, painful, swollen acne treatment. They are best suited for comedonal acne which would be your blackheads and your whiteheads. For drying pimple creams, like benzoyl peroxide, salicylic acid, calamine lotion, I don’t recommend applying these to areas that have broken skin.
If you apply these to broken skin, the irritation and drying potential is just going to be multiplied. Potentially, you are going to end up with something that looks like a chemical burn. That is something much redder with a lot of peeling flaking and bad scarring.
Instead, I would recommend using an anti-inflammatory product with botanical-based extract that doesn’t contain anything irritating like salicylic acid. For example, the one we use is based on an algae. There is no issue applying this over areas with broken skin, although it also really depends on the formulation itself.
In addition, for a correctly labelled and medicated acne cream, i.e. not just a cosmetic product, there would be very clear indications of use available.
Does my skin ever get used to pimple-clearing products – is that why my pimple never seems to heal?
If you are using a medication like clindamycin and erythromycin, then yes because you develop real bacterial resistance which stops the medication from working. If you are using something which is drying such as the first category I spoke about earlier, or something anti-inflammatory, there is no evidence that your skin can actually develop a form of resistance to that. It is simply that the severity of acne has progressed or in the first place it wasn’t sufficient acne treatment.
Adult Acne Treatment
For patients with mild acne, they will have approximately 3-5 pimples every month and they tend to be of the teenager age group. Once you are past your teenage years, from the age of 21 onwards, it is a different ballgame of what dermatologists term as adult acne. If you still suffer from acne then, meaning having an average of more than 5 pimples every month after the age of 18, it is at the minimum, a case of moderate acne.
Moderate severity acne means that while you don’t have severe scarring or cystic acne, it is still very persistent and would need to be treated medically by an accredited dermatologist. In my clinical experience, moderate acne does not respond well to topicals only regimens. Topicals are only useful as an adjunct in the treatment of moderate acne.
On the other hand, using appropriate cleansers and pimple-clearing gels works well and is sufficient for mild acne. It may be a selection bias by default, given that attendances at a dermatologist practice would be moderate cases.
This is because the mild cases perhaps get treated at the GP level before they do get to us. Moderate cases of adult acne would need more treatment than just topicals. According to international dermatology guidelines, there are two options for the treatment of adult cystic acne.
Oral Acne Treatments
Firstly, the oral pathway for which I must emphasise that there are many oral medications that are safe and effective that have been widely prescribed by dermatologists internationally for decades. Examples of commonly prescribed medications include low dose oral antibiotics like doxycycline, erythromycin. These function primarily as anti-inflammatory medications to prevent comedone formation.
Minocycline is less frequently used these few years as it has been linked to a few rare cases of hypersensitivity syndrome, on top of potentially causing blue-grey skin discolouration.
Erythromycin in particular is safe for pregnant and lactating individuals. Oral contraceptive pills such as Diane-35 and Estelle-35 contains estrogen as well as cyproterone, which blocks androgen (testosterone activity). Androgens are male hormones that trigger off oil production, exacerbating adult hormonal acne.
Women with a history of irregular menstrual periods with cystic acne may have undiagnosed polycystic ovarian syndrome (PCOS). Such individuals will benefit from joint management of a dermatologist and a gynaecologist. Treatment of PCOS is with hormonal therapy, which will benefit adult acne treatment as well as preventing infertility.
Non-Oral Acne Treatments and Physical Therapies
Secondly, we have the non-oral pathway for acne treatment which involves physical therapies that have to be administered in a clinic setting. For example the usage of LED wavelengths, blue-light, two times a week for one month.
Blue light is therapeutic for treating acne that is especially worsened by the bacteria Propionebacterium Acnes. This has been proven to be effective in a regimen of twice weekly 30 minutes duration for a one month regimen.
Chemical Peels and Lasers for Acne Treatment – Can they be used independently?
Use of chemical peels and specific lasers like the carbon laser helps to shrink the oil glands of someone with active acne, especially in individuals that may not want to go on oral medications.
I always recommend those with persistent moderate acne to go for a short course of a safe antibiotic such as erythromycin or doxycycline in conjunction with any of these physical therapies. This is the most cost-effective option that targets inflammation that goes on in acne rather than blindly treating it from the surface.
For severe acne, you may suffer from deep painful cysts which often involve pus and bleeding and there will be a lot of scarring. The treatment for this is very straightforward, our first line is always this medication called isotretinoin.
The medication is also known as accutane or oratane which are brand names of the forms of isotretinoin available. Isotretinoin is an extremely effective oral medication which works essentially by shrinking your oil glands.
Without oil, your skin simply doesn’t produce acne. However, isotretinoin use does come with drawbacks like increased sun sensitivity, dryness of the lips and eyes. One also has to monitor your liver function and cholesterol levels whilst on isotretinoin.
A lot of patients in my practice have asked me to gauge the number of days to determine if an acne product works and my answer is simply this.
The Wound Healing Process of a Pimple’s Life Cycle
When a pimple forms it is best viewed as an injury caused by inflammation to the skin. You may go by the principles of wound-healing, especially when it only involves the top two layers of the skin (the epidermis and dermis).
Within the first 2-3 days of a cyst, there should be signs of pus draining. Should there be blood coming out of it, soon one should observe the redness and swelling resolving as well.
Acne That Does Not Heal
Acne may progressively accumulate and get larger instead of reducing in size. For example, the acne may get more painful, accumulate more pus and blood that doesn’t seem to be draining. When this occurs, one has to consider that there is an underlying cyst forming.
What is An Acne Cyst?
The formation of an acne cyst involves the collection of haemoserous material – blood, sebum, dead skin, keratin and debris. These substances subsequently get “cordoned off” by the body with a wall around it. This is part of the immune system’s response to inflammation. Acne cysts do not respond well to any topical treatment.
Proper Treatment of An Acne Cyst
Acne treatment of cysts involves a combination of the following. Firstly, an injection known as an intralesional steroid injection helps to reduce inflammation locally. It is injected right into the centre of the nodule and within 3 days, swelling will reduce the underlying swelling.
It is very important for the injection to be administered. This is because untreated acne cysts can lead to more severe problems like facial abscesses with drainage of pus.
Furthermore, it can spread to other parts of your face which is rare but has been documented. Concurrently, large painful acne cysts should be treated with an oral antibiotic such as amoxicillin, sufficient to treat the secondary bacterial infection that causes this reaction.
In the light of the Covid lockdown, our clinic is open to TeleDermatology services for acne treatment. This includes complimentary doorstep courier of prescription, contactless delivery within 3 working days. Same day delivery can also be arranged.
If you suffer from mild to moderate acne, you may try these over the counter cosmeceuticals proven for acne treatment.
In my previous articles, I have talked about cosmeceuticals and the importance of incorporating them in our daily routines. However, how do we enhance the skin absorption of these cosmeceuticals? Here I will be talking about the limitations of topical formulations and how we can overcome them to ultimately achieve the results that we desire.
The problem with topical formulations for your skin
The outermost layer of the skin, called the stratum corneum, acts as a natural barrier. It prevents foreign material from entering our system, shields us against environmental factors and prevents excessive water loss. The skin is a formidable barrier to the passage of substances into and out of the body, but it can be manipulated to allow it to become a viable pathway for drug administration.
Drug products applied to the skin’s surface penetrate the skin layers to a certain extent, where they can exert their effects. This is the case for topical formulations for treatment of skin disorders such as acne, dermatitis, and psoriasis. However, very few drugs are suitable for delivery by the topical route, as passive penetration through the skin is limited to very small molecules (<500Da), which are neutral and relatively lipophilic. Some considerations of dermatologists would be the vehicle of the topical, specifically if it is in a lotion, cream or ointment form, in increasing order of absorption and effectiveness. This however, is often limited by user preferences, with ointment formulas (more efficacious) deemed cosmetically less acceptable.
The skin is the largest organ of the human body, comprising 15% of body weight and therefore its use to deliver medicine to the body is not a new concept by any means. Advancements made by modern science are improving the skin’s potential as a route for drug administration. Dermatologists are at the forefront of research relating to transdermal drug delivery, given the unique accessibility of the largest organ of the body.
Owing to the drawbacks of topical formulations, transdermal patches have been developed to improve drug delivery through the skin and this is an area that my team has actively researched in the last year as an adjunct to our cosmeceutical formulations.
I have always been interested in finding new methods to allow my patients to achieve optimal results from our cosmeceuticals, thus in this article I shall share some tools which I employ in my clinical practice to achieve optimal absorption of cosmeceutical active ingredients.
Wet Wrap/Occlusion Skin Therapy & Facial Masks
A well known method employed by dermatologists to treat severe eczema known as wet wrap is actually a simple process involving applying a wet textile together with topical medications to skin, to increase absorption of skincare. An example of how and when wet wraps are used— during particularly intense eczema flares with severe itch or pain, wet wrap therapy rehydrates and enhances the absorption of topical medications applied on the skin. The fabric wraps are soaked in water and applied to the affected skin on the body. Wet wraps are best done after bathing, moisturising and applying topicals, then left overnight.
Wet wraps work via 3 different ways:
● Cooling — as water gradually evaporates from the bandages this cools the skin and helps relieve inflammation, itching and soreness
● Moisturising — cosmeceuticals covered over with wet bandages are deeply absorbed in to the skin to provide a longer-lasting moisturising effect
● Absorption — enhanced absorption of any topicals into both the superficial and deeper layers of skin where inflammation is present
Facial sheet masks work in a similar way, on the basis of occlusion. This means that when there’s a topical which is applied on the skin and also in contact with something moist such as a sheet mask, there is increased absorption of the topicals by the skin. In my practice, whenever I want to increase absorption of cosmeceuticals and moisturisers that are dispensed to patients, I would advise them to apply a wet cotton sheet (as a wet wrap) on to their face to increase absorption.
I would consider masking as something which is very good to do if you are already diligent with other aspects of skin health such as cleansing and applying cosmeceuticals. Using a face mask would deliver moisture and clinically active ingredients to the skin—so it is important to look out for ingredients such as glycerin, ceramide and hyaluronic acid, as well as evidence-based antioxidants for anti-ageing such as oligopeptides, vitamin C ( I use sodium ascorbyl phosphate which is a neutral, rather than acidic form of vitamin C, that has minimal skin irritation). Here’s a tip, use a cosmeceutical moisturiser like the Radiance Fluide™ and increase your skin’s absorption by applying it on damp skin, plus a soft wet cotton towel over it.
Performing a facial massage, such as with the aid of a facial roller before application of cosmeceuticals could increase the skincare absorption, leading to better effects of the anti- aging skincare. Local massage is an established treatment method of improving surgical scars, by stimulating blood flow and improving wound healing. A peer-reviewed study published in a medical journal Complementary Therapies in Medicine led by author Miyaji Akane at the Institute for Liberal Arts, Tokyo Institute of Technology (Tokyo Tech) and colleagues at Tokyo Healthcare University and the Research and Development Center, MTG Co. Ltd. in 2019 had examined the effects of using a facial roller on facial skin and blood flow. The study concluded that there was significantly increased vascular (blood vessel) dilation with use of the facial massage roller. This means that there will be increased absorption of any cosmeceuticals applied on the face following the massage.
My recommendation would be manual rather than electric facial rollers as the latter may cause excessive pressure and irritation (being automated) and is also dependent on user training as well as the manufacturer’s settings, with a potential risk of overheating of electric components. Manual facial massage is a self-regulated process as the user can immediately sense irritation and apply just the right amount of pressure.
Transdermal medications (usually in the form of a patch) are a little more modern and complex. Great strides in transdermal drug delivery have been made since the first transdermal drug was approved by the FDA in 1979.
Transdermal drugs bring medication through the skin, to the bloodstream. Once in the bloodstream, the ingredients circulate and take effect at a targeted location. Medication is delivered steadily and can be stopped simply by removing the patch. Since your body doesn’t have to digest the medicine through the stomach, a higher concentration reaches the bloodstream. The medication permeates the skin in a controlled fashion thus attaining more ready levels of the drug in the body.
The science behind polymers and transdermal drug delivery systems
Polymers are vital in a transdermal drug delivery system. Systems for transdermal delivery are assembled as a multilayered polymeric laminates consisting of a drug reservoir sandwiched in between 2 polymeric layers:
● An outer impervious backing — prevents the loss of drug
● An inner polymeric layer — functions as an adhesive and rate-controlling membrane There are 3 types of transdermal drug delivery systems:
● Reservoir systems
In this system, the drug reservoir is embedded between a backing layer and a rate-controlling membrane.
● Matrix Systems
In this system, the drug reservoir is either dispersed in an adhesive polymer or in a hydrophilic or lipophilic polymer matrix.
● Micro-reservoir Systems
This system is a combination of the above 2 systems. The drug reservoir is formed by suspending the drug in an aqueous solution and then dispersing the solution in a lipophilic polymer to form thousands of microscopic spheres of drug reservoirs.
Polymers used in transdermal delivery systems should have biocompatibility with the drug and other components of the system. They should also provide consistent, effective delivery of a drug throughout the product’s intended shelf life.
An example of a common polymer used are silicones, also known as polysiloxanes, made of many repeating units of siloxanes. Siloxanes are chains of alternating silicon and oxygen atoms that are often combined with carbon and/or hydrogen. Medical grade silicones are silicones that undergo specific testing for their biocompatibility and have been deemed appropriate to be used for medical applications. Topical silicone therapy is often used by plastic surgeons and dermatologists to treat and heal scars.
Key considerations of a polymer patch used for transdermal drug delivery would be —conformability of the material to be applied to irregular skin or scar surfaces, sensitive regions such as the face/eye area and the overall durability and biocompatibility of medical grade polymers.
The process of skin ageing relates to the ability of the body’s natural healing processes. The same cells which are activated during cell injury are the ones which lose function with ageing, and are responsible for loss of collagen, elastin and the overall loss of volume and elasticity of skin. Specifically, antiageing cosmeceuticals target and stimulate cells known as fibroblasts, which are best thought of as the “soldiers” of wound healing which produce collagen to seal up injured or damaged skin. Injury to the skin occurs over a gradual process in the case of ageing, due to the slowing of one’s biological clock and photodamage.
For the last year, my team and I worked with a material scientist to develop a transdermal delivery patch, the QRASER™ Transdermal absorption patch, launched in July 2019. This patch works via a matrix system of drug delivery. In this system, the drug reservoir is dispersed in an adhesive polymer matrix. The transdermal delivery patch uses a unique polymer technology that mimics the natural hydration and homeostasis of the skin barrier, to enhance cosmeceutical absorption. The focus is on improving absorption via optimisation of the skin healing microenvironment.
The result? Healthy collagen production thus reducing fine lines and wrinkles.
In conclusion, cosmeceuticals in the arena of dermatologist-led skincare research will be increasingly prominent in the next decade of “smart skincare”. This should be emphasised along with understanding of how these topicals work, the limitations of skincare absorption and potential technologies such as transdermal delivery patches which can optimise the anti-ageing benefits of cosmeceutical skincare.
Dr. Teo Wan Lin, founder and medical director of TWL Specialist Skin & Laser Centre, is one of Singapore’s prominent dermatologists specialising in medical and aesthetic dermatology. She is also the founder of Dr.TWL Dermaceuticals which specialised in cosmeceutical skincare. In July 2019, a material science arm Dr.TWL Biomaterials was launched focusing on novel biomaterials for skin and hair application. Click here for the links to our product and here to read more about Dr.TWL Dermaceuticals and here to read more about Dr.TWL Biomaterials.
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Melanin is the culprit behind the dark spots that give us an uneven complexion. It is a brown pigment found in the basal layer of the epidermis.
This pigment is synthesised by melanocytes. The process of melanin synthesis is termed melanogenesis. Melanocytes go through different stages of maturation, becoming more pigmented at each stage.
Certain stimulants trigger a gene to produce more of tyrosinase, a copper-containing enzyme that converts tyrosine into melanin. Stimulants that activate the melanocyte include hormones, inflammation (such as acne) and external environmental conditions (ultraviolet light that causes the production of free radicals).
One simple way to reduce melanin production is to use broad-spectrum sunscreens with zinc oxide, titanium dioxide or iron oxide. These substances help block UVA and UVB light, thus impeding the stimulation of melanocytes.
Pigmentary disordersfrom melanin
Common hyperpigmentation disorders that involve the darkening of an area of skin due to increased melanin include melasma, lentigo, and post-inflammatory hyperpigmentation.
Melasma is usually caused by chronic exposure to ultraviolet radiation or a spike in hormones due to pregnancy or the use of oral contraception. It can be found at the epidermis, dermal layer or mixed, depending on the location of the pigment.
A lentigo is a light or dark brown area of discoloration that can range from 1mm to 1cm across, and is caused by an increased number of melanocytes. Its outline is usually discrete, but can also be irregular. Simple lentigines arise mostly during childhood on areas not exposed to the sun. Solar (or senile) lentigines are found on the backs of hands or on the face, most commonly after middle age.
Post-inflammatory hyperpigmentation (PIH) is the skin’s response to inflammatory skin disorders. Common causes are acne and atopic dermatitis. PIH is caused by the overproduction of melanin caused by skin inflammation.
Treating hyperpigmentation from melanin
Hydroquinone: For 50 years, hydroquinone has been the gold standard treatment for hyperpigmentation. This compound inhibits tyrosinase activity, thus limiting the amount of melanin to be produced. It also alters melanosome formation, possibly degrading melanocytes.
However, prolonged use of topical hydroquinone has shown to have side effects such as ochronosis and permanent depigmentation. Ochronosis is a disorder with blue-black discoloration. As such, hydroquinone is banned in cosmetic formulations and only available through a prescription that should be carefully managed by an accredited dermatologist.
Retinoids are forms of vitamin A that can treat acne, photodamage and PIH. They have various pathways that lead to skin lightening effects, such as accelerating epidermal turnover, reducing pigment transfer and slowing the production of tyrosinase.
With common side effects being erythema, skin irritation, dryness and scaling, it is recommended to use a retinoid only under the supervision of an accredited dermatologist. Corticosteroids (steroid hormones) have anti-inflammatory abilities and are often prescribed along with retinoids to prevent excess irritation.
Arbutin is a botanically derived compound found in cranberries, blueberries, wheat and pears. Though arbutin is a derivative of hydroquinoine, it has shown to be a more controlled way of inhibiting the synthesis of melanin as it does not permanently destroy melanocytes.
Kojic acid is a naturally occurring fungal substance. Its skin-lightening ability works by inhibiting the activity of tyrosinase. However, frequent use can cause side effects of contact dermatitis or erythema (redness of the skin).
Azelaic acid is known to be effective for treating PIH and acne. Azelaic acid depigments the skin in several ways. It can inhibit tyrosinase or reduce levels of abnormal melanocytes. This means that azelaic acid does not influence normal skin pigmentation but only acts on the proliferation of unwanted melanocyte activity. Side effects are mild and only last for a short period of time. Irritation, burning sensation or mild erythema may emerge, taking 2 to 4 weeks to subside.
Niacinamide is a derivative of vitamin B3. It works by decreasing the transfer of melanosome to keratinocytes. Niacinamide is a stable ingredient as it is unaffected by light, moisture or acids. This ingredient is often incorporated into cosmeceuticals due to its safety profile.
Vitamin C or L-ascorbic acid is a naturally occurring antioxidant that helps with skin lightening. It prevents tyrosinase from converting tyrosine to melanin. Vitamin C is also favored for its anti-inflammatory and photoprotective properties. However, L-ascorbic acid is highly unstable and rapidly oxidized. It is not used in the treatment of PIH.
Stable forms of vitamin C include magnesium ascorbyl phosphate or sodium ascorbyl phosphate. For safe and effective results, consider a dermatologist-formulated serum VITA C GOLD™ Serum,a formulation tested for bio-activity in a laboratory.
As seen above, there are various treatment options to treat common hyperpigmentation disorders. Recognizing the underlying cause for pigmentation is critical for proper treatment and choosing the best-suited therapy. Visit an accredited dermatologist for effective and safe treatments catered to your condition.
Dermarolling, also known as microneedling, has become popular in treating acne scarsand it can be used safely in a dermatologist’s clinic by an accredited dermatologist, as a simple office-based procedure.
It is a minimally invasive procedure that uses fine needles to puncture the epidermis to create micro wounds that stimulate the release of growth factors and induce collagen production. The procedure is painful and a prescription numbing cream is used to numb the skin before the treatment. Overall, the epidermis remains relatively intact and doesn’t seem to have many side effects when performed by a trained professional and with sterilised equipment. To date, the procedure seems to be generally safe and low-cost method of improving acne scars. However, there are insufficient studies as yet to support the use of microneedling for various conditions as an evidence-based method.
Functions of dermarolling
Dermarolling can be used for enhanced delivery of applied medications, “transdermal delivery” of cosmeceuticals such as vitamin C and vitamin A derivatives (retinoids) but this is best used with caution. In my personal experience, it can cause irritation and there is no conclusive evidence to suggest that it is superior to an optimised topically applied cosmeceutical alone. It has also been used for the treatment of hair loss, with steroids delivered for conditions such as alopecia areata, although it is not preferred over conventional methods of steroid injections for this autoimmune condition.
It lasts 10 to 20 minutes and informed consent is obtained about the expected outcomes, delayed response, and need for multiple sessions. Dermatologists also prepare the skin preoperatively for at least a month with vitamin A and C formulations twice a day to optimise results, such as enhancing dermal collagen formation.
Dermarolling at home?
There has been a proliferation of ‘home-care dermarollers’, which are of shorter needle length less than 0.15 mm for improvement of skin texture such as pore size, fine lines, sebum production and delivery of anti-ageing products. Some have also been developed for coverage of larger surface areas such as legs and buttocks for stretch marks and cellulite. In my view, there is insufficient data supporting the safety and effectiveness of home care dermarollers and is not recommended. For conditions such as acne scars, it is far more effective to recommend ablative fractional resurfacing.
On a related note, dermarollers carry risks which may be far more pronounced in the at-home group including the following.
Infection. Medical microneedles are currently made of medical-grade stainless steel presterilized by gamma irradiation and are for single use only. Home dermarollers are usually made of smaller shorter needles, for multiple uses (other than washing in hot water, but this does NOT eliminate all viruses and bacteria, including a type of tap-water tuberculosis bacteria known as atypical mycobacteria). It is hard to predict how deep a home user may end up traumatising their skin, whereas when it is performed by an accredited dermatologist, sterility of the instrument as well as proper technique is applied.
Dermarollers should NOT be used in patients with anyone with these following problems i.e. keloidal tendency, active acne, skin infection such as Herpes labialis or warts, chronic skin diseases such as eczema and psoriasis. Those with blood clotting abnormalities, or on anticoagulant therapy, chemo/radiotherapy are at high risk of bleeding and suffering rare infections using non-medical dermarollers.
Dermarolling may seem like a ‘less invasive’, easier or more novel option to traditional ways of treating acne scars, but it is definitely less effective than laser therapies. However, it has been used mainly in medical studies as a combination treatment with surgical/laser therapies to enhance results. It is also popular in darker skin types, as these patients can have a higher risk of developing hyperpigmentation as a side effect to ablative laser treatments, whereas microneedling does not seem to carry the same risk in such groups.
Dermarolling is only recommended when performed by an accredited dermatologist. Even then, common side effects are redness and irritation (which usually subside within a few hours) and patients are often informed of the risks of scarring: post-inflammatory hyperpigmentation, worsening of acne and reactivation of herpes, systemic hypersensitivity, allergic granulomatous reactions (such as sarcoidosis) and local infections following the use of a nonsterile instrument, such as home-use dermarollers. In addition, there have been reports of allergies to materials used in the needles. Improper technique, such as when performed by a non-medical professional, can result in worsened acne scars, and injury.
There is not yet clear data available to substantiate the length of time which effects of dermarolling could last. Also, depending on the severity of the condition and what dermarolling is used for, it is important to note that severe conditions such as ice pick or box car acne scars or photoaging will not have dramatic improvement effects from dermarolling alone, but will benefit from a combination of laser/injectables/cosmeceuticals with or without dermarolling. Skin healing goes through different phases and occurs differently at different ages, with individual genetic differences, which will all play a factor in determining how long and how dramatic the benefits of dermarolling and treatments in general will present.
Laser Therapy is the use of different invisible wavelengths of light to stimulate distinct layers of skin in order to rejuvenate and anti-age skin. Pigmented lesions can also be effectively removed with specific lasers that cause crusting and stimulate pigment cells (known as melanocytes) to disseminate.
Who is Laser Therapy for?
Laser Therapy is indicated for the following skin concerns.
Minimisation and/or the elimination of veins and redness
Non ablative lasers differ from regular forms of laser therapy. Instead of heating and removing the top skin tissue, non-ablative or non-wounding lasers work beneath the surface skin layer. They aim to improve skin texture and tone and minimize fine lines present with minimal side effects and recovery down time. Primarily used to treat facial skin rejuvenation and acne scars, according to a patient’s skin type and condition, non ablative laser therapies computer-control the parameters of light energy delivered from light-based devices.
Meet with Dr. Teo Wan Lin, founder and Specialist Consultant Dermatologist of TWL Specialist Skin & Laser Centre, an accredited dermatologist specialising in medical and aesthetic dermatology. She integrates her artistic sensibility with her research background and specialist dermatologist training, by means of customised, evidence-based aesthetic treatments using state-of the-art machines, injectables (fillers and toxins) which work synergistically with her proprietary line of specialist dermatologist grade cosmeceuticals Dr.TWL Dermaceuticals.
To book an appointment with Dr. Teo, call us at +65 6355 0522, or email firstname.lastname@example.org. Alternatively, you may fill up our contact form here.
Acne Scar Treatment is a series of refined dermatological techniques which are performed on a patient to improve the appearance of his/her skin and to boost his/her self-esteem.
Who is Acne Scars Treatment for?
Acne Scar Treatment is for those with deep permanent scars such as pitting or crater-like scars caused by severe acne.
What are the types of Acne Scars Treatment available?
Based on the nature of the scarring by acne, the patient’s medical history, the dermatologist will choose a technique or combination of treatment that is most suitable for the patient. The below-mentioned techniques and procedures are commonly used to in improving acne scarring.
Laser Therapy: By delivering short pulses of the laser beam, dermatologist are able to smoothen, sculpt and normalize the appearance of acne scars. The non ablative and ultrapulse carbon dioxide lasers are commonly used for treating acne scars.
Chemical Peel:By applying a chemical solution to the skin, mild scarring and comedogenic acne can be treated. It also improves your skin tone and reduce pore size.
Excision and Punch Replacement Graft: By surgically removing a depressed acne scar and replacing it with a patch of skin from elsewhere on the patient’s body, excision and punch replacement graft can improve acne scarring.
Soft tissue fillers: By injecting a small quantity of hyaluronic filler or a patient’s own fat, taken from another part of the body, below the surface of the acne scarred skin, these soft tissue fillers are able to elevate depressed scars.
Adjunct Cosmeceutical Treatments: The use of skincare with bioactive ingredients targeting the healing of scars such as oligopeptides which enhances collagen growth, can help maximise the benefit of Laser and Chemical Peel treatments. These treatments does controlled damage to the epidermis and stimulates collagen growth to heal scars. The Elixir-V Serum for example, which is infused with oligopeptides and potent antioxidants, is frequently used by our patients as adjuncts during acne scar treatments.