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  • Acne is a common problem, and concerns regarding topical antibiotic usage, coupled with an increase in antibiotic resistance, have made surgical and procedural approaches to acne more attractive.

  • Surgical approaches may address primary acne lesions or post-acne scarring.

image Beginner Tips

  • Inflammatory acne may be treated with chemical peels or laser and light-based approaches.

  • Intralesional triamcinolone may be used in very low concentrations on a very occasional basis for select inflammatory papules and nodules, but its use is limited by the side-effect profile.

image Expert Tips

  • Intralesional corticosteroids may be injected directly through the top of inflammatory acne lesions.

  • Ablative fractional laser resurfacing may be useful for acne scarring, and provides much of the benefit of ablative laser therapy with minimal risk of dyspigmentation or scarring.

image Don’t Forget!

  • Many acne patients are of child-bearing potential; intralesional injections, chemical peels, and most other invasive treatments should probably be avoided in patients who may be pregnant.

image Pitfalls and Cautions

  • Aggressive use of intralesional corticosteroids may cause significant atrophy and telangiectasias.

  • Patient education regarding postprocedure sun protection for PDT is critical.

image Patient Education Points

  • Patient expectations should be carefully managed, as an understanding of the expected degree of improvement will help mitigate the risk of disappointment and frustration.

  • Acne is a chronic condition, and no treatment will lead to definitive cure; explaining this to patients may help control expectations.

image Billing Pearls

  • With the exception of intralesional injections, most surgical and procedural treatments for acne are not covered by insurance in the United States.

  • Since many treatments require multiple visits, offering patients a discounted rate for multiple treatment packages may encourage compliance.


Acne is a multifactorial disease, caused by increased sebaceous gland activity, follicular hyperkeratinization, changes in immunological response, and obstruction of the infundibulum.1 Retinoids or antibiotics are typically considered first-line treatment options, and work by exerting anti-inflammatory effects and attacking Propionibacterium acnes (P. acnes). However, the numerous side effects and growing antibiotic resistance associated with these approaches, coupled with a small but important subset of patients who fail to respond, highlight the need for procedural therapies.2

Despite the advent of light and heat therapies, comedone extraction and intralesional injection remain in vogue, due in part to their significant efficacy. Recently however, techniques such as photodynamic therapy (PDT) have increased in popularity due to both their efficacy and safety profile.


In 1900, Thibierge introduced the extraction of comedones as the first physical therapy for acne treatment.3 While this method results in immediate improvement, it is associated with a risk of tissue damage and the possibility of incomplete extraction. Lowney et al. showed that comedone extraction reduces the recurrence rate of ...

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