If patients are crying in dermatologist Dr. Tatyana Hamilton’s exam rooms, it’s usually for one of two reasons, she says — acne or hair loss.
But a recently approved “revolutionary” laser treatment, the first major breakthrough in acne treatment in about two decades, may change that.
The laser has been used in clinical trials for a number of years, but Hamilton Cosmetic Dermatology in Victoria, which includes Dr. Thomas Christensen, is the first in Canada to use the machine commercially since Health Canada cleared Cutera’s AviClear energy device in mid July as safe for the treatment of mild, moderate and severe acne and acne scars.
The Health Canada safety clearance followed approval from the U.S. Food and Drug Administration in March.
“Technically we’re not the first machine in that sense, but we’re the first one to be available to patients outside of clinical studies,” said Hamilton, an active clinical trial investigator and researcher. “This is a medical condition, so we’re just thrilled to have another tool in our toolbox.”
Cutera, based in California, was reported in July as planning an expansion of its AviClear device to Canadian providers in a limited commercial release over 2022.
Acne is often thought to be an affliction of youth that goes away with adulthood, but it can start in infancy — acne affects 20 per cent of newborns, according to the Canadian Dermatology Association — and extend into middle age.
And it can have a significant impact on patients’ physical and mental health and social lives, said Hamilton.
“Everybody is affected differently and sometimes we don’t appreciate the degree of the sort of mental suffering they have,” said Hamilton. “It affects all spheres of their life up to the ability to keep to keep full employment, so yes, they do cry in the office.
“I have had patients who would say: ‘I missed my prom or I didn’t go out on a date, I did not want to go out and meet my friends because I had this horrendous outbreak, I had to hide and cry, all the way up to suicidal ideation.”
People have killed themselves over acne, said Hamilton.
Acne, or acne vulgaris, is a skin problem that starts when oil glands — sebaceous glands, containing fatty material called sebum — become clogged by layers of dead skin cells.
Bacteria within pores, called Cutibacterium acnes, can result in inflammation and subsequent blackheads, pimples or red painful lumps or cysts, according to Health Canada.
“At the root of it is hyperactive oil glands, the sebaceous glands, and we have a lot of them, particularly on the face,” said Hamilton.
Acne affects 5.6 million Canadians, nearly 20 per cent of the population. More than 80 per cent of acne sufferers are between the ages of 12 and 24. In teens, hormones drive excess oil production.
For about 20 years, the dominant treatments for acne have included non-prescription benzoyl peroxide and salicylic acid and retinoids, prescription topical creams, prescription pills including isotretinoin, commonly known as Accutane or Clarus, oral antibiotics and anti-inflammatories, and hormonal therapies, including birth-control pills.
Isotretinoin, prescribed for an average of six months and long considered the gold standard of treatments for severe acne because of its effectiveness, shrinks oil glands and unclogs pores.
Isotretinoin, however, also comes with many possible side-effects, from dry skin to joint pain, a high risk of severe birth defects in pregnant women, and potential for depression and psychosis.
The AviClear energy device does the same job as isotretinoin, as it selectively focuses on suppressing sebum production. The recommended treatment is three 30-minute laser treatments. The energy the laser produces is adjusted for different skin types and colours.
Hamilton monitored clinical trials in the United States: “I know the technology is excellent.”
Clinical trials, said AviClear, demonstrated that current and future breakout episodes are shorter, less intense and more infrequent following the procedure.
“Whether it’s mild, moderate or severe acne, they see a uniform efficacy across all degrees of severity and all skin types, so I’m very comfortable with it,” Hamilton said. Youth in her practice must have a parent or guardian’s consent.
While Hamilton says the laser is a game changer, dermatologist and researcher Dr. Jerry Tan wants to see more data on how the laser does compared with other treatments.
“I think it’s innovative,” said Tan in a phone interview. “It’s extremely exciting. I’m super-excited to think it might be a game changer but I’m kind of less in that camp until I see the data.”
Tan has a clinic in Windsor, Ont., and is an an adjunct professor at the University of Western Ontario, and researcher of acne and acne scars. He is using the AviClear laser in clinical trials.
Tan is currently recruiting patients with moderate to severe acne for randomized control trials to compare how the laser works compared to no treatment at all.
It would take even more data to compare how the laser compares to other treatments, but Tan imagines more clinicians will simply start using the laser commercially in combination with topical treatments if necessary.
“And if it looks like you simply need the laser by itself as a monotherapy, fabulous, if you need to consider using it with a topical, fabulous, but maybe then we can reduce the need for systemic pill treatments for acne,” said Tan.
“This is a really important treatment because there is no other option that we currently have that is as selective for acne as this one is, nevertheless, it’s one within a whole group of options.”
Hamilton and her laser technicians underwent training on the newly arrived AviClear machine in late August and treated their first patients.
University of B.C. student Vanessa Wedick, 20, was hoping to lose her mild facial acne and scarring and gain back some confidence.
“It does make me insecure and there’s a lack of confidence that comes with knowing you have these marks on your face, even if people say it’s normal,” said Wedick. “And when it’s really flaring up, it’s made me really self-conscious and, honestly, wanting to socialize less.”
Wedick has found temporary success with the oral antibiotic Doxycycline but it also came with side-effects such as photosensitivity. She hasn’t wanted to try isotretinoin.
While Hamilton argues acne is a medical condition and laser treatment should be covered by MSP along with prescribed pills and creams, she acknowledges the health-care system is already overburdened and “the reality is lasers are expensive.”
Currently the laser treatment — including a package of three sessions — costs about $3,000 in the United States and $3,800 in Canada. A 2016 report on the cost of recommended treatments estimated a three-month prescription of oral isotretinoin would cost $395 to $480.
Hamilton’s business is about 80 per cent medical patients, with a separate office dedicated to cosmetic dermatology for the remaining 20 per cent of her clients. “I will always be medical-based. I’m quite old-fashioned and I just feel it’s my duty to provide medical care first.
“The reason for aesthetic work originally was to treat some of those medical conditions that we couldn’t treat with prescription medications and to free up my time to engage more time with my medical patients in the way that all doctors want to.”