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Abstract
Background and Objectives: The flare up induced by isotretinoinduring the first two months of acne treatment is a
common unwanted effect. The increased inflammatory immune response due to destruction of p. acnes bacteria
is suspected.
High intensity narrow band 405'-420nmlight sources, (iClear/ClearLight/Clear100)were found to be effective both in
the photodestruction of p. acnes bacteria in vitro and in vivo, and in the reduction of proinflammatorycytokines in
keratinocytescultures.The purpose of the current study was to examineif the exposureto a high intensity405-420nm
light has an effect on the incidenceand the severityof isotretinoininduced acne flare ups.
Study Design/Material
and methods: 40 Patients with a severe acne received 8 sessions of blue light (iClear,
CureLight Ltd.), twice a week during a month, and had a follow up visit every month for 3 months. Oral isotretinoin was
prescribed to all patients (0.6mg/kg) for 8 months. The group A was treated by the blue light for four weeks prior to
starting isotretinoin.The group B started blue light and isotretinoinsimultaneously.
Results: Both groups (22 patients) had less flare ups than expected with full dose of isotretinoin «30%). Flare ups
occured morefrequentlyand lasted longer in group A (11 patients)than in group B (11 patients).
Conclusions:
Acne phototherapy by high intensity narrow band 405-420nm light when associated during the first
month with oral isotretinoin. is diminishing the occurrence of flare ups induced by isotretinoin.
Introduction
.
Isotretinoin (AccutanefRoaccutane@) therapy of acne has been associated with inflammation. exacerbation, and acne
fluminans [1, 2, 3; 4, 5, 6, 7]. Flare ups usually appear 3-5 weeks after commencing isotretinoin therapy. These flare ups
cause a major social and psychological burden to the patients and may induce severe long lasting scarring.
Severity varies from one patient to another. Young acne patients, males and patients with large white comedones prior
to therapy are more susceptible to develop acne flare ups during isotretinoin therapy.
It was observed that improvement occurs upon suspension of isotretinoin or reduction of the dose, and that increases
in dosage aggravates inflammatory symptoms.
Clark and Cunliffe [2]. studied 980 patients treated with isotretinoin. They reported a flare of acne in 59 patients. Most
patients had the flares within 3-5 weeks of commencing treatment. Mean percentage increase in acne grade was 38%.
Severity of flares was closely related to extent and size of non inflamed large comedones >1.5 mm present prior
to treatment.
Pre-existing sebaceous gland occlusion has been emphasized as a predisposing factor in several other reports [2, 8, 9].
Clark and Cunliffe hypothesize that the decreased size of the sebaceous glands caused by the Isotretinoin cause an
abrupt destruction of p. acnes causing the release of large number of antigens. These antigens provoke an outstanding
local inflammatory response clinically manifested as acne flare up or acne fulminans.
The role of the initial dose is controversial. Some authors note aggravation at doses of 1 mg/kg/day [2, 10], but cases
of acne fulminans have been reported with doses lower than 0.5 mg/kg/day [1, 11]. Karvonen et al. described seven
patients with acn-efulminans induced by isotretinoin. The mean isotretinoin dose in these patients was 37 mg/day and
flare up started on average 7 weeks after isotretinoin was started.
The initial site of acne does not appear to be a predictor of aggravation, as patients acne flared on both the trunk
and face.
Treatment of flares is controversial. The following have been proposed: continuation of isotretinoin alone [1, 12] or associated
with systemic steroid therapy [7, 13]; reduction of the dose of isotretinoin in association with systemic steroid therapy [14, 15];
and suspensIon of isotretinoin [16] and"institution of systemic steroid therapy [4, 6,10,14] at doses of 0.5 to 1 mg/kg/day.
High intensity narrow" band 405-420nm light sources, (iClear/ClearLight/Clear100) were found to be effective both in the
photodestruction of p. acnes bacteria in vitro and in vivo, and in the reduction of proinflammatory cytokines in keratinocytes
cultures. [17-21]
The purpose of the current study was to examine if the exposure to a high intensity 405-420nm light has an effect on the
incidenceand the severityof isotretinoininducedacne flare ups.
Material and methods
Fortypatientswere enrolledin the study.All patientswith a severeacne received8 sessionsof blue light (iClear,CureLight
Ltd.), twice a week during a month,and had a follow up visit everymonth for 3 m<!>nths.
Oral isotretinoinwas prescribedto
all patients(O.6mg/kg)for 8 months.
GroupA was treated by the blue light for four weeks previouslyto the beginingotisotretinoin. Group B started blue light
and isotretinoinsimultaneously.
Results
Both groups (22 patients) had less flare ups than expected with full dose of isotretinoin «300;0). Flare ups occured more
frequentlyand lasted longer in group A than in group B. Figures1-3.
Conclusions
A recently published study by Holland et al. shows a clear relationship between tendency to scarring after acne to peri
follicular inflammatory process in the individual patient [22]. Acne phototherapy with high intensity violet/blue light recently
gained an important place in the armamentarium of acne therapy [17-21]. It was proven to be effective as an alternat!veto
antibiotic anti acne therapy and for patients that do not need, can not or are reluctant to have isotretinoin oral therapy. This
study shows that acne phototherapy with violet/blue light (iClear, CureLight Ltd.) is effective in diminishing the number and
severity of isotretinoin induced flare up. This is more significant when acne phototherapy is performed during the first month
of oral isotretinoin treatment. It is hypothesized that violet/blue anti acne phototherapy reduces the bacterial antigen load
expected 2-3 weeks after start of isotretinoin therapy and decreases the inflammato,ryprocess which is the major cause for
the isotretinoin induced acne flares. This study shows that non thermal selective acne phototherapy maybe an important tool
when prescribing isotretinoin for acne and may reduce the incidence and severity of the acne flare up induced by these drugs.
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