Discussion

Physical therapies may be directed against either the secondary prevention of early lesions or the destruction of established lesions. For true primary prevention of early lesions the pathogenic process is insufficiently described to allow a causal therapy, although the use of laser depilation may yet prove to be fruitful in proper studies. The possible effect of PDT on the hair follicle is at present unclear. It is not convincingly proven that the penetration of ALA-PDT is sufficiently deep to allow treatment of established lesions of Hurley category II or III. Nor is it established that ALA-PDT has any effect on sinus tracts. The effects may therefore be more in line with the effects of this treatment in acne vulgaris, where a significant clinical effect has been shown in some studies. ALA-PDT is however associated with considerable post-treatment pain and inflammation in acne patients and this may also limit its use in HS.

These reservations however stem partly from the paucity of data, and partly from the practical consideration of penetration. It is entirely conceivable that the photosensitizers used do not penetrate the tissue sufficiently because of their formulation. A more liquid preparation may allow deeper penetration of the photosensi-

tizer into the hair follicles. The use of red light is theoretically sufficient, but even here there is room to improve the scope of this modality. In general the paucity of data requires additional well-designed studies, which should initially be relatively small, strongly structured proof-of-concept studies. With current technology the justification of an actual randomized controlled trial is debateable.

Destructive methods have to respect the general surgical principle of tissue conservation, i.e., that healthy tissue should be left intact. In HS sinus tracts normally occur under healthy skin which need not be destroyed. Precision in the application of destructive methods is therefore very important. While indiscriminately destructive methods such as cryotherapy, and probably also electrodesiccation, may be expected to work, they also induce unacceptable collateral damage. In addition unnecessary tissue destruction induces significant iatrogenic morbidity in the patients, as the lesions are often slow to heal, are susceptible to suprainfec-tion and cause additional scarring. With improved imaging techniques and more targeted delivery of treatment this could be overcome to some degree, but is unlikely to be removed altogether.

A number of hypothetical and speculative physical approaches may be imagined. Improved lesion imaging may for instance also allow future intralesional therapies with application of light or pharmaceutical substances directly into the lumen of the lesion. Similarly, radiofrequency devices may provide relief via an effect on the connective tissue surrounding the lesions. Finally, UVA1 therapy may provide an anti-inflammatory effect as well as scar reduction if applied locally. It is most likely that the potential of a series of novel physical therapies will be explored over the coming years.

Acne Myths Uncovered

Acne Myths Uncovered

What is acne? Certainly, most of us know what it is, simply because we have had to experience it at one time or another in our lives. But, in case a definition is needed, here is a short one.

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