PHOTODYNAMIC LED LIGHT THERAPY WITH OR WITHOUT ALA FOR ACNE

Many patients (and their parents) have asked us for alternatives to traditional acne therapies that include oral medications, and irritating topical creams. Many of the oral antibiotics can affect the bone marrow or liver, can cause diarrhea or yeast infections, and do require at least once yearly blood monitoring. They can interfere with birth control pills. One can be allergic at any time to a single dose of any antibiotic, and there is always the concern of bacterial resistance and lowered immunity. Rarely there can be life-threatening diarrhea (pseudomembranous colitis). Antibiotics have been successfully used for years and they have their place, as do the topical therapies including benzoyl peroxide and the retinoids (Retin A, Tazorac, and Differin). Nonetheless, patients for various reasons cannot tolerate these medications because they may have had side effects or they don’t want to take them anymore.

Accutane, a potent vitamin A derivative, is an effective treatment for acne but it too, may have multiple side effects requiring monthly blood tests. Among the most serious are depression including suicidal thinking, serious birth defects, and effects on the bone marrow, blood lipids and liver.

Because of this, Dr. Coverman and Jennifer Jordan, PA-C have developed a comprehensive and brand new program for patients who no longer want to use oral or even topical acne products. This is all light-based and completely avoids the need for any blood tests or worries about pregnancy issues, depression, or the effects on internal organs.

Dr. Coverman was the first doctor in Austin to use lasers for the skin. He was likewise the first to use the CO2 laser, the Erbium laser, and Plasma for resurfacing of the skin. He was the first to use lasers for acne (Smoothbeam), and he and Jennifer Jordan now proudly announce that they are first to bring Omnilux LED therapy to Austin! LED stands for Light Emitting Diodes, and these are very similar to the glowing light on your VCR or TV even when you "turn it off." The difference is that these are now used in a bank containing hundreds of these lights that are very carefully focused to uniformly bathe the skin in specifically chosen healing wavelengths. LEDs are painless and are not lasers. This is not ionizing radiation such as xray, and LEDs cannot cause cancer. There is no pain or discomfort, and most treatments last 20 minutes. There are several LED devices on the market, most of them cheap. Dr. Coverman chose Omnilux because most of the significant and published research has been produced and performed by Phototherapeutics, the makers of Omnilux. They have done most of the significant worldwide research regarding the use of LEDs for acne, photoaging, precancers, and vitiligo. Dr. Coverman and Jennifer Jordan specifically chose Omnilux because it is currently the only such device offering three different wavelengths that may be delivered at specifically different times. This is critical because research has shown that if two or more wavelengths are delivered simultaneously, the effect may be diminished or neutralized. With sequential treatments alternating wavelengths, the best results are achieved. Competitors such as Gentlewaves (yellow) or Clearlight (red and blue) do not offer enough wavelengths or sequential wavelengths.

The Omnilux™ LED has three different treatment heads which each emit a specific wavelength:

Omnilux Blue™ - 415 nanometers (nm). The blue wavelength produces singlet oxygen cells that work to kill the bacteria in your acne lesions. Most bacteria that cause acne produce a byproduct chemical called protoporphyrin 9. The blue wavelength is specifically absorbed by this chemical, and thus “finds” the bacteria that produced it. The singlet oxygen cells kill the bacteria only, and thus acne is improved.

Omnilux Revive™ (Red) - 633 nm - The red light is purely anti-inflammatory - visible redness and inflammation is immediately reduced.

Omnilux Plus™ - 830 nm - This third wavelength actually promotes skin rejuvenation and healing, and in fact it is the wavelength we use for wrinkles and photo rejuvenation in older patients. It can likewise rejuvenate and improve acne scarring and skin damage.

If your acne is more severe, and you need more aggressive therapy, we will add ALA to this. ALA stands for aminolevulinic acid. This is a non-painful clear liquid that we simply apply to your face one hour before the actual 20 minute LED treatment. The liquid itself doesn't’t hurt, and doesn’t do anything for the acne. What it does do is photosensitive your skin, and particularly the acne lesions such that the LED treatment works better and penetrates deeper. Because of this, you will be extremely photosensitive that day and especially the next day. If you will read our instructions below, we will explain exactly how to avoid problems and take care of your skin.

If we are going to apply the ALA, you must wash with a special soap at home in order to “degrease” your face. The soap is available for purchase at our office. When you arrive at the office, our medical assistants will apply the ALA to your face which just takes just a few minutes. You will then go out to our waiting room, and sit for one hour while it soaks in. Bring your homework, book, or your iPOD. While you are sitting there you won’t feel a thing - it doesn’t hurt at all! After that hour, we will then call you back to start your 20 minute LED treatment. What you can expect with the addition of the ALA is described below. The light itself doesn’t hurt and doesn’t burn, but is bright. You will be wearing eyeshields. After a specified amount of time, the lights will automatically turn off and your treatment is finished.

When the treatment is finished, the inflammation will start, and we will recommend topical therapy for that. There may be pain and discomfort. We will take care of that also. You may be pink to red for several days, and this may be followed by peeling for the next week. In some cases, there may a response without any redness at all, and if so, we will repeat the procedure next time with a longer incubation time of the ALA. There is a rare chance of immediate pain and extreme redness due to a photo toxic response that could not have been predicted. If so, we will immediately stop your treatment. If so, there could be blistering, oozing, and so forth, but we have topical medicines that can help minimize this effect. This is rare.

In general, we only use this for the most severe cases, and normally the LED treatment protocol for acne is alternating the red and blue wavelengths twice a week for four weeks (eight treatments). When we add the ALA, we use this on the very first treatment and then very last treatment. This will thus be a total of 10 treatments. It is critically important to complete all 10 treatments - the best effect is afforded when the cumulative dose has been given.

There is generally a nice reduction in the inflammatory component of acne. The actual number of bacteria is reduced, and we hope to give you a long-term remission after the eight or 10 treatments have been completed, even rivaling Accutane. No blood tests are needed, and there is no risk of birth defects or depression. This treatment is best for inflammatory, nodular, or cystic acne but doesn’t work as well with comedones (blackheads). Thus we may have you continue to use a salicylic acid type wash or application product and a product like Differin which loosens blackheads.

The main contraindications to using this type of photosensitizing therapy is the potential for an exaggerated response to the light. You must not be taking any medicines that could be photosensitizing. The more common ones are certain diuretics, antibiotics that are any form of tetracycline, and antifungals. Likewise, if you have any photosensitive disease such as porphyria, lupus or albinism you should not do this treatment. Because the treatment is inflammatory it can flare herpes, and if you have a history of oral herpes anywhere on your face or in the treated area we will prescribe for you a series of anti-herpes pills to take the day before, the day of, and the day after your treatment. Even so, herpes infection could still break through. From this you could have pigment or scarring just like in any herpes infection.

LEDs are just that - light emitting diodes! They are not lasers and they don’t hurt. You cannot scar or burn. This is not ionizing radiation (like xrays or UVA/UVB) and you will not get skin cancer. This is simply high intensity light at very specific wavelengths that is delivered in a beautifully designed cross-hatched pattern so that all areas desired are treated evenly at the proper wavelength.

In breaking news presented at the American Society of Laser Medicine and Surgery in April, 2007 it has now for the first time been shown that infrared pretreatment of skin with LED’s may protect against UVB exposure just as well as a sunscreen but in a way that is unaffected by moisture or perspiration, environmental factors, allergy or compliance. The protection is equal to that of an SPF 15. This was at the 660 nanometer wavelength.

Although this is new information and not necessarily recommended for clinical use (it is still cheaper, faster and more efficient to apply the sunscreen), it is further proof that this device is indeed remarkably safe and protects against ionizing radiation rather than causing it.

DR. COVERMAN HAS PERFORMED THIS PROCEDURE ON HIMSELF. PART OF THE INSTRUCTIONS YOU READ BELOW WILL BE SPECIFICALLY FROM DR. COVERMAN’S OWN EXPERIENCE.

INSTRUCTIONS FOR PHOTODYNAMIC THERAPY WITHOUT ALA

Bring your iPod! The treatment lasts 20 minutes, and after awhile it simply gets boring. Make sure you bring the small plug-in earpieces, larger earphones such as Bose and so forth will be too bulky and get in the way.

The lights are extremely bright - shockingly so. We will give you appropriate eye protection, but the brightness of the light may surprise you. Do not be scared - this can’t hurt you and actually after you lie there for awhile it will seem less bright even though it isn’t. In fact, at some point you may even find it soothing, and some patients fall asleep.

Although there is some heat generated, it is not painful at all. We will have a very strong fan blowing across your face, so heat should not be a factor.

If you ever had herpes or think you may have, tell us! We will prescribe a series of anti-herpes pills to take daily beginning the day before, the day of, and the day after. Make sure you already have this prescription filled! Even so, herpes could theoretically breakthrough which could cause pigment and scarring.

You should not have any laser or any light based therapy if you have any photosensitive diseases such as lupus erythematosus, porphyria, or albinism. You must stop any photosensitive medicines at least two days before your treatment unless your prescribing doctor told you not to. Always check! These include anti-arthritis drugs such as gold or methotrexate: any antibiotic from the tetracycline group including Tetracycline, Minocycline, Doxycycline, Vibramycin, Doryx, Solodyn, and Dynacin; acne medicines including Accutane, Cipro, or any of the "quinolone medications"; oral antifungals including Griseofulvin; anti-arrhythmia drugs including Chlorpromazine; NSAIDs including Naprosyn, Advil; St. John’s Wort; diuretics.

INSTRUCTIONS FOR PHOTODYNAMIC THERAPY WITH ALA

Plan your visit late in the afternoon. Then just before coming to our office, wash your face with a salicylic acid acne wash (DCL Active Cleanser).

On the day you complete the treatment with ALA, please arrive at our office one and a half hours prior to your treatment time. When you arrive we will cleanse your skin to degrease it and remove any fatty residues.

We will apply the ALA - the ALA itself doesn't hurt.

You will have to wait in the office for one hour for adequate penetration - please wear comfortable clothing and bring something to read. We have WIFI internet access and you may use your computer for the web. Bring your iPod! The treatment itself lasts 20 minutes, and after awhile it simply gets boring. Make sure you bring the small plug-in earpieces, larger earphones such as Bose and so forth will be too bulky and get in the way.

For the treatment you will lie down in front of a bank of lights. Generally, most patients don’t feel anything other than mild warmth during the 20 minutes that the lights are on. Very rarely however some patients do have an immediately painful reaction to this type of photosensitization. You will know it right away, and you can tell us and we will immediately shut off the lights. Simple icepacks in the office will calm that down. The lights are extremely bright, even with the protective eyewear that we will give you. When you lie down we will put the bank of lights extremely close to your face. Your eyes will be covered but even then some patients may find this claustrophobic. Again if you normally have a problem with this, tell us before and we will give you a Xanax of Valium here at the office to make this more comfortable for you. If you require a Xanax or Valium you must schedule and arrange for a driver to take you home. The procedure will take exactly 20 minutes and the lights will automatically shut themselves off. This is where the iPod helps.

At the conclusion of the procedure we will apply sunscreen and ask that you go directly home and avoid any sun exposure that day and particularly the next. Your face will be extremely photosensitive for the next 24 hours, and you will actually feel burning and stinging directly on your skin with even five seconds of direct sunlight exposure. Even sitting in your automobile behind the glass is not a great idea. You might want to take the next day off.

Although there is some heat generated, it is not painful at all. (See above - some patients do experience immediate discomfort if we have applied ALA.) We will have a very strong fan blowing across your face, so heat should not be a factor.

Your face will start to turn red, and sometimes intensely red. Don’t let that scare you - that is exactly the reaction we want and expect. You will be red when you leave, but the maximum redness will be visible by the next morning. At that point you will be extremely photosensitive - surprisingly so! Dr. Coverman noticed that even when he walked out to get the newspaper at 8:00 in the morning, his face immediately began to sting and he wasn’t even in direct sunlight. By 9:00, just walking from his car to the office, the low rays of the sun literally stung his face immediately. Even driving over to the office under the window glass of the car was a bit uncomfortable. We highly recommend that if you must be in the sun, you apply a “chemical-free” sunblock - even these might sting a little bit going on, but are free of other chemicals known to sting. Without any sunblock, as Dr. Coverman found out just walking up to the back door at 9:00 a.m., immediate exposure to the sun, within seconds caused a surprising amount of sharp pain.

Obviously if you go to work, you will have this sun exposure so wear the sunblock in the morning.

Ideally, don't get any sun exposure at all!

Tylenol would work fine the second day, but you may also take Advil, Aleve, or the Ultram one more time.

As soon as you get home, if you feel discomfort we recommend the following regimen.

POST-TREATMENT PAIN

For normal post-operative pain following most of the procedures that we perform in our office, we do not recommend nor prescribe any of the stronger pain medicines including hydrocodone (Lortab; Darvocet N100; Mepergan Fortis; Ultram). We feel that a combination described below of over-the-counter medicines will be enough. This is what we recommend:

Take one Aleve or Advil pill every 4-6 hours with food. Wash it down well with liquid. Breakfast, lunch, dinner and bedtime snack.
Do not take Aleve or Advil if you are allergic to aspirin, ibuprofen, naproxin, these pills, or have any type of aspirin sensitivity or the syndrome of nasal polyps, allergies, atopic eczema, and aspirin-allergy. Likewise, do not take this if you have any bleeding problems, or have ever had any ulcer disease or similar stomach disease.
We also recommend that you take two Extra Strength (500 mg) Tylenol tablets every 4-6 hours as well at the same time.
Please remember that the side effects of Tylenol have nothing to do with the side effects of Aleve or Advil, thus these may be taken together.

If you have any liver disease or potential liver problems, do not take the Tylenol. Do not take Tylenol if you are allergic to it or acetaminophen. DO NOT DRINK ALCOHOL WITH THIS REGIMEN! Otherwise, follow the schedule below:

8:00 a.m. - Breakfast
One Aleve or Advil with breakfast and plenty of water.
Two 500 mg Tylenol for adults.
Noon to 2:00 p.m. - Lunch
One Aleve or Advil with lunch and plenty of water.
Two more 500 mg Tylenol.
6:00 p.m. - Dinner
One Aleve or Advil with dinner and plenty of water.
Two more Tylenol.
10:00 p.m. to midnight - Bedtime
One Aleve or Advil at bedtime and plenty of water.
Two more Tylenol.
Benadryl (diphenhydramine) 25-50 mg for sleep.

The Benadryl is a great idea. It is the main component of most over-the-counter sleeping pills. (Tylenol PM), and is not addicting. Never drink alcohol before or with this, and plan on going right to sleep and sleeping 8 hours. DO NOT take with any other sleeping pill, anti-depressant, MAO inhibitor, or anti-anxiety drug (Xanax, Valium, etc.). Do not drive or operate dangerous equipment.

Thus, in any given day you should never take more than the total of four Advil or Aleve or eight Tylenol total (two every four to six hours).

Normally you should be able to safely do this for one to three days - but never more. If the pain ever worsens or this fails to control it - call our office during normal office hours or the medical exchange (458-1121) after hours.

This combination of Aleve or Advil plus Tylenol is safe, covers you around the clock, and allows you to take two different pain medicines whose side effects don’t cross react with each other assuming you are not allergic to either.

HEALING CREAMS

Silvadene Cream - apply this every morning and you will find this extremely soothing and healing. It is normally used for burn victims so it will certainly be soothing for you.

Synalar Ointment - Apply this in the evening - this is an extremely soothing cortisone ointment that will dramatically reduce inflammation and hence pain. Make sure you get the OINTMENT, not the cream - creams to have fragrance, color, and preservatives. The ointment will be much more soothing although it is also much more greasy. It would even help to refrigerate the ointment when you are not using it.

Use these right away and for the first week afterwards.

Men should shave as normal on the day of your treatment. You probably won’t want to shave for two to three days afterwards - so plan on this. If you must shave during the healing phase we do not recommend razor blades. They will cut you too close. Simply use an electric shaver, and even then just "buzz off" the top of your hair and do not attempt to get an actual close shave. All that rubbing will simply irritate your skin further and you won’t want to do that.

Use common sense! Do not use any astringent soaps, or any skin care products at all, no matter who tells you what they are for. Please use only those topicals we have discussed and/or prescribed.

After seven days you may resume normal activities, but be sure to keep the Heliosol Sunscreen or chemical free sunscreen on your face at all times. Dr. Coverman did this procedure on a Monday but was able to play golf on a Friday wearing a double layer of sunscreen and a broad-brimmed hat. We recommend EltaMD UV Physical SPF 41. This is a chemical-free sunblock that won’t burn or sting. It is waterproof with excellent adhesiveness. Dr. Coverman has used this specific sunblock on his own face, not only after the actual treatment, but even during the red and peeling phase. He found that it did not sting. He was also able to play golf with this liberally applied six days after his treatment.

When applying sunblock, wash and dry your face thoroughly to get the oil off the skin so the sunblock will penetrate into your skin and not sit on top of your oil. Apply it evenly and THICK. Most studies have shown that people don’t apply enough of the product. Wait five minutes, and then apply a second coat all over again! Do this one hour before any intended sun exposed activity. It does no good to apply sunblock at the very last minute while on the golf or tennis courts or at the pool. You are already exposed, you are already sweating, and any sunblock will drip right off. Always apply a double layer of sunblock thickly at your home one hour before any intended sun exposure.

Wear broad brimmed hats - the broader the brim, the better. Baseball caps are simply not good enough. Purchase and use a broad "golf umbrella" if you must be in the sun.

Do not plan this treatment around any trips to the beach, or any obvious sun exposed vacations.

Plan this treatment around your school, travel, work, and social calendar. You are going to be fairly bright red for a minimum of one to two weeks after the treatment, so plan on that. After that, the redness will fade and it will look more like a sunburn reaction. You may have intense peeling or flaking.

If you ever had herpes or think you may have, tell us! We will prescribe for you an anti-herpes medication to take daily beginning the day before, the day of, and the day after. Make sure you already have this prescription filled! Even so, herpes could theoretically breakthrough which could cause pigment and scarring.

We don’t mean to scare you with all of this but we did want to give you some alternatives and some recommendations. Dr. Coverman does have a bit of chronic sun damage and did get a little excess burn from the sun but found that the Tylenol alone was fine. Patients with actinic keratoses may get even more inflamed so we just wanted to give you a little “cookbook” of what you can do to make this more comfortable. Some patients may not need any of this at all, so don’t feel obligated. On the other hand, if you are uncomfortable - don’t hesitate to use any of the above regimens if they are not otherwise contraindicated.

If you have any questions or concerns - please call us at 345-9411 during the day or through the medical exchange at 458-1121 after hours.

FINAL REMINDERS - Things to purchase before your visit:

Silvadene Cream for the morning (prescription)
Synalar Ointment at night (prescription)
Aleve or Advil (over-the-counter)
Tylenol 500 mg pills (over-the-counter)
Broad brimmed hats - Bring to office
EltaMD UV Physical SPF 41(sold at Dr. Coverman’s office) - Bring to office
A broad “golf umbrella” if you must be in the sun - Bring to office
DCL Active Cleanser (sold at Dr. Coverman’s office)

On the days that you undergo the LED treatment with the ALA, you will only need to wash your face with the DCL Active Cleanser prior to your arrival. Your in-office time should not exceed 30 minutes unless we are running behind. After we bring you back to the procedure room your face will be cleansed again to degrease it, but immediately thereafter we will begin the 20-minute light treatment. Don’t forget to bring your iPod and following the light-only treatments you will be able to resume all activities as normal.

FEES

Omnilux LED: Eight treatments twice weekly - $100 per treatment session ($800 total) or $700 prepaid "package."

Omnilux LED w/ ALA: One treatment with ALA - $125 + $100 per treatment session. ($225 total).

We strongly suggest that you complete all of the intended treatments to get the best long-lasting result. Although each treatment will make a difference and each treatment will help, the cumulative effect will be greater than the sum of individual treatments alone. To encourage compliance and for your convenience, we have offered a discount for you if you pay for the full package up front. If you cannot complete all of the treatments for any reason, we will of course refund your money.

If the full pre-purchased package cannot be completed for any reason (including but not limited to: disinterest, perceived lack of results, moving, illness, or other circumstances), the unused treatments will be promptly refunded, but the treatments that were already used will be repriced at the individual treatment price per treatment x the number of treatments delivered, and then the refund will be subtracted from that.

All fees are subject to change. The fee is always what is current at the time of your actual treatment. Old fee schedules, handouts, or web site fees do not apply. Any quoted fees must be in writing and are only good for six months. No "verbal" quotes are accepted.

SCHEDULING

Dr. Coverman or Jennifer must see all patients prior to the first treatment in order to discuss your eligibility, intended results, possible contraindications, and the concurrent or previous use of other oral and topical medications. There is a fee for this visit - there are no free consultations. Dr. Coverman or Jennifer will examine you and discuss your care, review prior and current medications, and outline a treatment program.

If you are an existing patient and have seen Dr. Coverman, Jennifer, Christi or Tammy previously for acne, please let our appointment receptionist know. In some cases, you may immediately schedule your first treatment without having to have that office visit. Once sessions have been instituted, we suggest that you schedule your sessions in advance such that your follow-up appointments will be easy to get. You don’t necessarily need to see Dr. Coverman or Jennifer during your sessions, but if you would like to discuss your regular ongoing acne care or make changes, please schedule an appointment with Dr. Coverman or Jennifer. There will be a normal fee for this visit.

There is a $150 non-refundable fee for missed appointments without a 24 hour notice.

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