Laser & IPL: Dr. Peter Crouch, MB.BS, Dr Steve Johnson, MD, Dr. Nicholas Soldo, MD

Ask a Doctor: Laser & IPL

Peter Crouch, MB.BS(T)GP, Clinical Director of The Burghley Park Clinic and Medical Director of the Great Western Laser Unit, Britain.

Steve Johnson, MD, Director, Tennessee Laser and Skin Rejuvenation, Sevierville, Tennessee, USA.

Nicholas J. Soldo, MD, Director, Arizona Vein & Skin Rejuvenation in Scottsdale, Arizona, USA.

Drs Crouch, Johnson and Soldo have kindly been answering questions about laser and IPL treatments on our direct-posting board the Rosacea Support Community

To help RSRP readers, here are abbreviated summaries of some questions covered, with links back to the original threads for those who would like to read the full Q&As.

Important pre-requisite disclosure for all participating doctors: Any advice or information provided here is general advice only. It is not intended to be, and should not be taken to constitute, specific medical advice given to any group or individual. Anyone who believes that he or she may be suffering from any medical condition should consult with a fully qualified, licensed medical physician who has the opportunity to examine the patient, take a medical history, and provide specific advice and or treatment based on their professional experience and expertise. General advice provided here should not be taken to replace or contradict advice provided by such a physician able to consult with the patient in person and provide specific medical advice.

ACCUTANE WITH RED LIGHT THERAPY OR LLLT

Q: Although it is recommended to leave about 6 months in between stopping Accutane and doing IPL/laser, can a patient stay on low-dose Accutane while using RLT or LLLT?

A: Dr Soldo: My opinion is that red light therapy should not be a problem. I am a big fan of RLT. As for LLLT (very low level laser), I have had no experience. I have not been impressed that it has any great value so do not include it in my practice.

http://rosacea-support.org/community/viewtopic.php?f=38&t=810

BEARDS

Q: Which is safer for beards – laser or IPL?

A: Dr Soldo: In 9+ years I have never seen permanent hair loss if not using deeper depth filters (above 700nm). Lasers are of more concern.

A: Dr Crouch: Hair loss can occur with laser or IPL but permanent hair loss is less likely with lower filter ranges. When offering triple passes to patients with rosacea, I generally omit the third pass (695nm and above filters) over areas where patients have indicated that they would not wish to lose the ability to grow hair, say a man’s beard area. There have been some (thankfully rare) reported cases of paradoxical hair growth stimulation with IPL.

http://rosacea-support.org/community/viewtopic.php?f=38&t=808

BLUE & RED LIGHT THERAPY

Q: How about blue light in combination with red light? Or the 830 nm LED used against pain? Is there any LED machine that you would recommend?

A: Dr Soldo: I generally reserve blue light for acne patients or rosacea patients with an acne component. I have used red LEDs in the 800 range for skin ulcerations etc and do not know their effect on pain. The most widely used LEDs are from Omnilux but can be pricey, but effective.

http://rosacea-support.org/community/viewtopic.php?f=38&t=810

DIFFICULT DIAGNOSIS: POSSIBILITY OF DISCOID LUPUS

Q: Patient was diagnosed with rosacea on the nose, but after 8 PDL treatments and some topicals, it was still not under control. One biopsy suggested possible discoid lupus but the next tests were negative.

A: Dr Soldo: It is impossible to make accurate comments from afar and I think it sounds like you have a reputable competent derm taking care of you and I suggest you follow his advice. We need to establish an accurate diagnosis. If it is rosacea then IPL is still the treatment of choice (not PDL) and might also be adjuncted with oral antibiotics and a nonsteroidal topical antiinflammatory.

http://rosacea-support.org/community/viewtopic.php?f=38&t=864

DIFFICULT DIAGNOSIS: RED HANDS AND ARMS FROM MEDICATION

Q: Can red hands and arms be symptoms of rosacea? Patient has permanent redness on face, thickening skin on the nose, and regular facial flushing and burning, but also permanently red hands and frequently reddened arms. He is on Gleevec for Chronic Myelogenous Leukemia.

A: Dr Crouch: The redness of your hands and arms are unlikely to be rosacea but more likely to be a systemic issue and treatment of the face is unlikely to help this aspect. Have you considered talking to you haematologist about these systemic vascular symptoms?

http://rosacea-support.org/community/viewtopic.php?f=38&t=1125

FACIAL STINGING & V-BEAM

Q: Please offer suggestions for treating facial stinging in response to social stimuli, heat, and physical exertion following V-Beam treatment, which also seemed to have triggered more seb derm. Patient has tried Lyrica, Klonopin, and antihistamines.

A: Dr Crouch: Sustained stinging after pulse dye is uncommon in my experience however it could be a commonly experienced symptom of rosacea and rosacea does unfortunately tend to progress. We use pulse dye laser to calm seb derm down and the effects last about 6 months. We use pulse dye laser to "immunise" the patient from the effects of the IPL which can often cause a flare in seb derm. Perhaps your seb derm was suppressed by the pulse dye sessions and flared up after the protective period elapsed?

http://rosacea-support.org/community/viewtopic.php?f=38&t=1048

IPL SETTINGS

Q: What are your current settings of joules/fluence? Also, do you feel results can be achieved for those not able to get to a Lumenis One Machine? If so, what joules/fluence are considered low yet effective, and should practitioners still use a triple pass as well?

A: Dr Soldo: There are no set joules to recommend. Each laser has different capabilities than those of other manufacturers. A good laser physician can get reasonably good results with most of the well known IPL/lasers. I like the Lum One because I have used it for so many years and am totally comfortable with it and all the possibilities it offers, e.g. multiple pulses that are not available on any other device. I feel that overly aggressive treatments actually create rather than destroy vessels. With IPLs a milder approach is more effective, producing much better results with less discomfort and less erythema.

http://rosacea-support.org/community/viewtopic.php?f=38&t=734

OCULAR ROSACEA

Q: Is there any study or trial showing that treatment with laser or IPL for facial rosacea will improve ocular rosacea symptoms? If so, which would be the best approach? (Patient keeps needing treatment for corneal ulcerations causing her to lose sight.)

A: Dr Soldo: In my office I would certainly advise IPL and good eye care. IPL will actually improve most cases of ocular rosacea however I find that patients do even better with the long term use of Oracea one tablet daily. Eye drops such as artificial tears and in some cases even Restasis are recommended. You have a very astute opthamologist so I would stick with him and his advice.

A: Dr. Johnson: I don't know of any studies but IPL seems to have more of a global effect to occular rosacea than V-beam or pulsed dye. Most patients seem to benefit from a combination of doxycycline and Restasis eye drops. Corneal ulcerations may also require an antibiotic drop with a steroid.

http://rosacea-support.org/community/viewtopic.php?f=38&t=986

TEENAGERS WITH ROSACEA

Q: Is it best to treat rosacea at an early age even if full symptoms aren't yet apparent, or wait for a full diagnosis?

A: Dr Crouch: I would always advise a treatment following formal diagnosis particularly with a relative youngster. Rosacea most commonly presents in the 3rd and 4th decade of life but many rosacea sufferers are younger. Consider discussing the condition with your primary care physician. If the diagnosis is rosacea, sometimes topical treatments (creams) or antibiotics are quite effective in the early stages.

A: Dr Soldo: I am very much in favor of IPL as early as possible with erythema and flushing. Our goal is to eliminate vessels and the fewer there are the better the results. There is no rational for waiting and younger patients can also utilize subclinical doses of doxycycline (ie oracea) and topicals.

http://rosacea-support.org/community/viewtopic.php?f=38&t=1108

THICKENING SKIN ON SIDE OF NOSE TIP

Q: Any suggestions for reducing nasal flare and thickening of skin on one side of the tip of the nose? Patient is on 100mg doxycycline per day, and uses Elidel and Noritate cream daily. Had 1040 Yag ND 2 years previously, now has V-beam 3 times per year. 10 mg of Accutane per day was too potent 3 years ago.

A: Dr Soldo: It might be reasonable to try Accutane at lower doses than before. Or a number of IPL sessions starting at milder settings, the more the better, continuing other meds already being taken.

http://rosacea-support.org/community/viewtopic.php?f=38&t=734

WHICH IS THE BEST LASER FOR RED SKIN AND MANY BROKEN VEINS?

Q: Which laser machine would work the best for a patient with smooth skin but a really red face and an awful lot of facial broken veins?

A: Dr Soldo: Any laser/IPL device is only as good as the person administering the treatment. All else being equal, IPL still gets better results than pulsed dye lasers for treating rosacea. My personal preference is Lumenis One for several reasons. It is a device I have used for many years and am fully versed in its use, plus it is the most versatile and powerful of all the other devices.

A: Dr Crouch: If your skin type could handle it

For redness, I would generally start off with three range IPL with the Lumenis One to tackle the fine vessels causing the diffuse redness. It may also selectively target the bigger discrete vessels on subsequent treatments. For discreet vessels that didn't respond, I would probably use the Gemini laser, either in Nd:YAG mode or KTP mode. For a patient that didnt respond to IPL, we might offer a purpuric (bruising) treatment with the NLite pulse Dye Laser initially but later return to the Lumenis One IPL to smooth and enhance results. For Seb Derm, we offer a non purpuric (non-bruising) pulse dye treatment called "An NLite chaser" to reduce the effects of the IPL on the Seb Derm.

http://rosacea-support.org/community/viewtopic.php?f=38&t=858

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Peter Crouch, MB.BS.(T)GP Dr. Crouch is a Section 12 Approved General Practitioner & Forensic Medical Examiner (Principal Police Surgeon for Thames Valley ). He is the Clinical Director of The Burghley Park Clinic and the Medical Director of The Great Western Laser Unit. Dr. Crouch uses Lumenis One (combined IPL/Nd:YAG), Gemini Dual Wavelength Nd:YAG, Chromogenix ("NLite") Pulse Dye Laser, Photogenica V-Star Pulse Dye Laser, Cooltouch III, Thermescent Nd:YAG. See also < Three range Intense Pulsed Light combined with Clarithromycin Protocol >

Steve Johnson, M.D. Director, Tennessee Laser and Skin Rejuvenation in Sevierville, Tennessee Web Site: Tennessee Laser & Skin Rejuvenation Dr. Johnson uses Lumenis One (combined IPL/Nd:YAG). As a rosacea sufferer, he is particularly interested in all aspects of rosacea treatment.

Nicholas J. Soldo, M.D. Director, Arizona Vein & Skin Rejuvenation in Scottsdale, Arizona. Web Site: Arizona Vein & Skin Rejuvenation Overview Dr. Soldo uses Lumenis One (combined IPL/Nd:YAG) plus the Iridex Varilite/Variscan. He is the Lumenis One medical trainer for South-West USA.