How to best optimize laser and IPL treatments has long been debated. Should the rosacean deliberately engineer a flush prior to treatment? Should anti-inflammatories or anti-hypertensives be taken after treatment? Of course, many have long since reached their own (perhaps tentative) conclusions and employed diverse means to prompt pre-treatment flushing and soothe post-treatment inflammation.

Yet, if sufferers have been quick off the mark, the givers of treatment – with a few laudable exceptions – and the makers of drugs, have been characteristically slow to catch on: too complacent to investigate and too un-enterprising to experiment.

The news that a bunch of presumably  bright people have decided to plough considerable resources into the development of a product comprising a topical vasodilator for pre-treatment, a topical vasoconstrictor for post-treatment, and a set of instructions on how and when to apply both, might just indicate that definitive answers to these questions are around the corner.

Control of Blood Vessel Physiology to Treat Skin Disorders

In a method for treating an affected skin region of a patient having a skin disorder, a vasodilation composition is applied to an affected skin region of a patient, the affected skin region exhibiting a skin disorder characterized by at least one abnormal blood vessel, and the affected skin region is then treated so as to non-invasively disrupt tissue architecture, e.g., by inducing ischemia, of the at least one abnormal blood vessel.

A vasoconstriction composition can then be applied to the skin region to cause vasoconstriction of the at least one blood vessel in order to promote healing.

[Full PDF]

Biochemics’ rationale for the use of the vasodilator is that it makes vessels easier to target and more susceptible to irreversible damage. The vasoconstrictor is applied to render vessel collapse and shrinkage more likely. Biochemics are collaborating with the laser manufacturer Cynosure and they have already conducted a trial of sorts.

The patent application is unusually readable and not without additional interest. For those who can’t be bothered but whose eyes lit up at the mention of vasoconstrictors, the constricting substances mentioned are: phytonin, phenyl-epinephrine, caffeine, arnica extract, cypress extract, Solomon’s seal extract, nymphaea alba flower extract, butcher’s broom extract, grapefruit oil, pomegranate and bugleweed extract.

Disclaimer: Apparently, it’s a lifetime’s work to formulate a vasoconstrictor that doesn’t cause rebound dilation, so, if you are minded to hunt any of these down, proceed with caution.

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Internal organs and cancer sites are now being treated with PDT using endoscopes and fibre optic catheters.

Even though some research papers about rosacea and PDT are available, as a rosacea treatment the usage of Levulan and light therapy combined is still experimental. Beware of possible adverse reactions if you are considering PDT as a skin treatment.

Fighting cancer with light

Though far more common in Europe, light-based therapy is gaining proponents in the United States.

Called photodynamic therapy, the technique represents part of medicine’s continuing quest for treatments that target tumours while sparing the rest of the body from unpleasant side effects. Though far more common in Europe, this light-based therapy is gaining proponents in the United States, where it has long been approved for treating certain lung and skin cancers.

… the therapy does have one significant side effect. The medicine that makes the tumor cells sensitive to light has a similar effect on the rest of the body. Regular cells excrete the medicine more quickly than do cancer cells, yet the kind of drug Correa received still had a fairly long impact. She would have to stay away from bright light for several weeks, or else suffer a bad sunburn.

…

In a randomized European study, photodynamic therapy had extended the life of patients with inoperable bile-duct cancer by more than a year, on average — in some cases several years. It worked so well that the trial was stopped early.

…

Correa received her infusion of the light-sensitizing medicine, called porfimer sodium, on Dec. 15. Two days later, she was placed under anesthesia, and Loren inserted an endoscope down her throat and into her small intestine.

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A recent segment on ABC-TV’s Good Morning America Health featured rosacea.

One slant put on this television story was promoted by a followup press release that highlights the use of Aesthera’s Isolaz technology.  In the past Aesthera’s combination of `pneumatic energy’ and broad band light has been used to treat the pustules and inflammation of acne.

Aesthera is now wanting to promote a `new tip’ on the Isolaz device which will allow it to target rosacea symptoms.

So the Isolaz treatment is IPL but with a suction head that reduces the pain usually associated with IPL treatments.

The Isolaz treatment hasn’t generated much discussion online. This is surprising considering such a high profile promotion on the ABC TV segment and that the treatment has been available since 2007. Dr. Day, a dermatologist from New York tells us that she herself has treated several hundred patients for acne and is now using the new treatment tip for rosacea.

User Reviews

If you are treated for rosacea with the Isolaz please do let us know how you got on in the comments below. How was the level of pain ? Did you see improvements ?

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A previous study in 1994 also found that Vitamin K cream reduced the severity of post PDL purpura.

Whilst the redness and indeed purpleness that Pulsed Dye Laser treatments can cause will heal without intervention, any option to reduce the downtime after treatment will be welcomed.

Pulsed Dye Laser treatments can also be extremely painful. A 2009 paper detailed the use of Pnuematic Skin Flattening to reduce the pain of PDL.

Topical formulations of Vitamin K Oxide are currently available via some doctors and indeed online. A product range from Biopelle known as Auriderm suggests the following to support the promotion of its’ products; “It’s the Vitamin K Oxide – not the Vitamin K – that clears unwanted discoloration and builds vasculature. Vitamin K was effective because it provided the raw material to create Vitamin K Oxide, which really did the work.”

The science of Vitamin K Oxide

Vitamin K has shown effectiveness in dealing with this because it initiates the Vitamin K cycle of healing: In the event of trauma, Vitamin K converts to Vitamin K Oxide, activating the Coagulation Factors in the clotting cascade. The cycle continues when Vitamin K Oxide converts back to Vitamin K, converting the staining ion (Fe+3) to the more easily absorbed ion (Fe+2), blocking and/or reversing the formation of hemosiderin.

Vitamin K itself is inherently unstable in topical formulations, perhaps explaining why Vitamin K topicals so far haven’t to date shown huge promise as rosacea treatments.

It is also worth noting that is has been shown that some people are allergic to Vitamin K. Also note that Auriderm suggests that Arnica Montana tablets be taken post-operatively, but some caution may be advised – Paula Begoun, in her article, When Blushing is Not by Choice: Causes and Treatments for Rosacea (web archive link), lists Arnica as something that potentially should be avoided.

Finally a related word of warning from a 2007 Scientific Committee on Consumer Products opinion on Vitamin K1 (phytonadione) suggested that;

Because of the inadequate nature of the dossier submitted, the SCCP is unable to provide an adequate safety evaluation for the use of vitamin K1 (phytonadione) and its "oxide" in cosmetic products. However, as such use may cause cutaneous allergy, individuals so affected may be denied an important therapeutic agent.

Now to the Abstract:

The role of topical vitamin K oxide gel in the resolution of postprocedural purpura.

J Drugs Dermatol. 2009 Nov;8(11):1020-4.

BACKGROUND AND OBJECTIVE: Facial purpura is a frequent barrier to patient acceptance and satisfaction with the results of various cosmetic procedures. Methods to shorten the duration of purpura after such procedures are often sought by patients. This study evaluated the efficacy and safety of a topical gel containing vitamin K oxide in the resolution of laser induced purpura.

METHODS: In this randomized, double-blinded, placebo-controlled split-face study, 20 subjects with bilateral facial telangiectasia were treated with a pulsed dye laser (PDL) device at purpuric settings. The test articles, a gel containing vitamin K oxide and placebo (vehicle), were each randomly assigned to one side of the subject’s face. Subjects applied the test articles twice a day for the following 9 +/- 1 days. Improvement in both focal and general field purpura on each side of the face was assessed by the investigator using photographs. A scale of -100% (worsening) to 100% (improving) was used to rate photos against a baseline photograph obtained 15-30 minutes after treatment with the PDL device.

RESULTS: Resolution of the field of purpura was consistently greater with the vitamin K oxide gel after the second day of treatment. The greatest difference between the vitamin K oxide gel and placebo scores occurred on the fourth day after treatment. Although differences in active versus placebo scores did not reach statistical significance during the nine-day study period, a trend toward faster resolution of purpura with the active product was seen. Treatment-related adverse effects were not observed in any subject.

CONCLUSION: Vitamin K oxide gel appears to hasten the resolution of pulsed dye laser-induced purpura in subjects being treated for bilateral facial telangiectasia, and may well be useful in accelerating resolution of facial bruising from other cosmetic procedures such as fillers used for soft-tissue augmentation as well as other types of cutaneous surgical procedures

As there are so few genuine treatments for the redness of rosacea, the availability and promotion of Vitamin K Oxide may lead to some interesting and useful options for rosacea sufferers.

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Pneumatic Skin Flattening uses a vacuum to compress the skin underneath the area being treated. Blood is eliminated from the treatment area. The technique is said to block pain naturally. One more more technical explanation for this effect is “The rational for applying negative pressure is the well-documented afferent inhibition of sensory nerves in the dorsal horn by activating tactile pressure nerves in a sufficiently large surrounding area.”

Note that this study relates to a treatment not directly related to the sorts of treatment regimes that are commonly associated with rosacea. Nonetheless any technique that reduces the pain of laser treatments is good news for rosacea sufferers.

Reduction of pain in the treatment of vascular lesions with a pulsed dye laser and pneumatic skin flattening, Lasers Med Sci. 2009 Jul;24(4):617-20, Lanigan S, Birmingham Skin Centre, City Hospital, Birmingham, UK.

The treatment of vascular lesions, including port wine stains (PWSs), with a pulsed dye laser is very painful and often requires general anaesthesia. This is particularly problematic with children.

Pneumatic skin flattening (PSF) is a new technology that naturally reduces pain in laser-based aesthetic treatments. The objective of this study was to test pain reduction, as well as lesional clearance, by combining pneumatic skin flattening (PSF) technology with a pulsed dye laser in the treatment of vascular lesions.

Twenty-one patients (three of them children) were treated for vascular lesions, mostly PWSs (13 patients). The patients were treated with a 595 nm pulsed dye laser operated at energies of 5.75–13.25 (median 9.25) J/cm².

Acute pain was evaluated in all 21 patients. Topical anaesthetic (EMLA cream) was applied before treatment in six cases. Identical energies were applied to both sites. The pain during PSF treatment was compared to pain during regular treatment without PSF. Blanching response to treatment was evaluated in 18 patients after 6–12 weeks.

Significant pain reduction was observed in 21/21 patients (100%). The average reduction in pain score was from 10 without PSF (painful) to 2.6 with PSF (comfortable).

Follow-up examination of 18 patients after 6–12 weeks showed identical blanching of tissue in both the PSF-treated areas and those not treated with PSF in all patients. It was concluded that the PSF technology significantly reduced pain in the treatment of vascular lesions with a pulsed dye laser without affecting efficacy.

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Clinical Trial NCT00945373: Combination Therapy for the Treatment of Rosacea

The purpose of this study is to determine the efficacy of calcium dobesilate in combination with pulsed dye laser for the treatment of rosacea.

Drug: calcium dobesilate 2.5% gel

Procedure: pulsed dye laser

All study patients will be treated with 595 nm PDL (Vbeam, Candela Corp, Wayland, Mass) with an initial test spot using a fluence of 10 J/cm2, 7-mm spot size and 1.5-ms pulse duration. Based on the biologic response of the test area, the fluence will accordingly be adjusted up or down to find a fluence that produces a transient purpuric effect for a few seconds only.

Several studies have shown successful treatment of rosacea-associated telangiectasia and erythema with pulsed dye laser. Moreover, calcium dobesilate (2,5-dihydroxybenzene sulfonate) is a drug that inhibits vascular smooth muscle cell growth and inhibits cellular proliferation. As a synthetic inhibitor of fibroblast growth factor (FGF), calcium dobesilate targets angiogenic growth factors which lead to uncontrolled blood vessel growth. In light of the fact that angiogenesis has been implicated in erythematotelangietatic rosacea, calcium dobesilate will be useful in the treatment of this subtype of rosacea.

Thus, combination treatment with PDL and calcium dobsilate will act in a synergistic manner to reduce the erythema, flushing and telangectasia associated with erythematotelangietatic rosacea.

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This paper is a further confirmation of the benefits of LED therapy post laser treatments.

More directly relevant to rosacea sufferers is a 2008 paper in Cosmetic Dermatology that also showed that LED helps recovery after IPL and reduces redness.

Further, this is building on the encouraging comments from the interview with laser and light therapy expert Dr. David Goldberg Combining Light-Based Treatments and Topicals for Rosacea.

The effect of IPL and LED appears to be additive. That is, the combination works better than each one separately. Papules & pustules are generally best treated with oral and/or topical agents. Inflammation or swelling is best treated with a combination of IPL and yellow/red LED. This group also is treated with near-infrared LED.

Here is the new abstract;

Improvement of Postfractional Laser Erythema with Light-Emitting Diode Photomodulation, Dermatol Surg. 2009 Apr 2, Alster TS, Wanitphakdeedecha R., Washington Institute of Dermatologic Laser Surgery, Washington, District of Columbia.

BACKGROUND The most common side effects of fractional laser skin treatment are erythema and edema. Low-level light therapy and light-emitting diode (LED) devices have been used to stimulate fibroblast activity and hasten wound healing.

OBJECTIVE To determine whether LED treatment immediately after fractional laser skin resurfacing affects the severity and duration of postoperative eythema.

MATERIALS AND METHODS Twenty patients received treatment with a 590-nm wavelength LED array to randomly selected facial halves immediately after undergoing full-face fractional laser skin resurfacing with a 1,550-nm erbium-doped fiber laser. Differences in erythema between LED-treated and untreated facial halves were recorded at 24, 48, and 96 hours post-treatment.

RESULTS The LED-treated facial halves were less erythematous in all 20 patients 24 hours postoperatively. The six patients who received the highest mean energy densities during fractional laser treatment continued to exhibit decreased erythema in the LED-treated areas at 48 hours. At 96 hours post-treatment, no discernible differences between facial halves were observed in any patient.

CONCLUSIONS Photomodulation with a 590-nm-wavelength LED array can decrease the intensity and duration of postfractional laser treatment erythema. The authors have indicated no significant interest with commercial supporters.

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Has anyone had their laser or IPL practitioner suggest LED as a post treatment therapy ? I wonder how long it will be before this form of recovery therapy will become the norm.

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The red swollen nose of rosacea is a much hated symptom. I know that this was the symptom that I despised most and indeed drove me 10 years ago to start to look for good information about how to treat rosacea. Incidentally, this drive lead to the creation of the internet based Rosacea Support Group in 1998.

I hated that I looked like I had adult acne and a constant sun-burned nose. Especially as I have somewhat fair skin, a red nose stood out a mile away.

There has been quite a lot of interest in a article I wrote titled “how to cure a red face (facial erythema or redness)“. That article gave some tips on how to deal with general facial redness. What about a red and swollen nose ? What can you do to treat a red rosacea nose ? Read on for some suggestions.

A rosacea nose has the extra complication that one might end up suffering from rhinophyma. Although rare, rhinophyma is also a much hated symptom of rosacea. While we don’t know for sure how any particular rosacea sufferer’s symptoms will progress, reducing your inflammation and flushing is a good start to winning the battle.

Here are my top tips for dealing with the red nose of rosacea.

Rosacea-LTD III

Rosacea-LTD was one of my first discoveries after starting to look for treatments on the internet in 1998. They consist of compressed disks of sulfur and various salts. You wet your face and glide them over the skin, leaving a thin film. For me these `disks’ did a great job of reducing the papules and pustules on my nose. I could feel them shrinking all those acne looking lumps and bumps. As much of my redness was associated with my papules and pustules, this treatment was a good step in the right direction. I continued to use rosacea-ltd for several years.

Disclaimer: rosacea-ltd is a site sponsor of rosacea-support.org

Oral Antibiotics

If the nasal swelling is associated with the papules and pustules normally seen in rosacea, then systemic antibiotics along with topical metrogel or finacea may also be of benefit. Once the papules and pustules are under control, the associated swelling may be reduced enough to see an overall benefit in appearance. One of the newer antibiotics on the market is a low dose form of doxycycline called Oracea, which may be useful in helping to maintain a long term benefit from antibiotic usage.

Accutane

Accutane or roaccutane has been used for many years to treat cystic acne. There is a good body of evidence to say that you can successfully treat rosacea with accutane. Additionally there are some published papers that deal specifically with treating rhinophyma with accutane.

Isotretinoin has also been demonstrated to decrease nasal volume in rhinophyma. The most significant regression has been noted in younger patients with less advanced disease.

…

Isotretinoin has also been demonstrated to decrease nasal volume in rhinophyma. The most significant regression has been noted in younger patients with less advanced disease.

Biopsy specimens from phymatous skin prior to isotretinoin therapy showed numerous large sebaceous glands. During isotretinoin therapy, the glands diminished in size and number. Other studies have confirmed the usefulness of isotretinoin for phymatous change.

[See treating rhinophyma with accutane]

Accutane is not a drug to be taken lightly. If you would like to try this as an option, the above references might help you find a doctor that can support you using this as a treatment option. You may also want to discuss the option of low-dose accutane with your doctor.

Covering Up

As you start to reduce the inflammation, you will probably also benefit from covering over some of the redness. Some options include the easily available Clinique Redness Solutions, or Eucerin Redness Relief which may be able to offer some relief from the redness. Additionally the green tinted version of the Tone Perfecting Cream may cover some redness.

Perhaps you can find some foundation or tinted moisturizer that you can also include in your daily regime. It might not be easily obtainable worldwide, but The Cancer Council in Australia has a range of tinted moisturiser SPF 25 that looks interesting. Don’t discount a liquid foundation as a possibility, even if you are a guy.

IPL and Lasers

We now know that IPL is excellent for treating a red face and broken blood vessels. Will any of the benefits of IPL also help a red swollen nose ? In general IPL and pulsed dye lasers are useful in reducing the redness flushing, burning,  itching, dryness and swelling of rosacea.

The AAD suggests that for thickening of the skin on the nose and cheeks as seen in rhinophyma, the CO2 laser and erbium:YAG laser can be used.

Surgical Options

When the growth of the nose tissue becomes impossible to manage with topicals or isotretinion, surgical intervention can be an option. Surgery can naturally have its own risks. With the removal of extra tissue also comes the risk of scarring.

CO2 Laser

A 2004  paper; The Gold Standard for Decortication of Rhinophyma: Combined Erbium-YAG/CO2 Laser, details how the authors suggest that the combined YAG/CO2 laser is superior to other lasers, scalpel, radiotherapy and skin grafts in dealing with rhinophyma.

Also some related comments from the AAD page Is laser treatment right for your rosacea? ;

Some patients with longstanding rosacea develop thickening skin on the nose and cheeks, which is called rhinophyma. The CO₂ laser and erbium:YAG laser can be used to remove this thickening skin and improve the contour of the nose. Other surgical procedures used to treat this condition include dermabrasion and excision with a scalpel. Treatment options may be combined to obtain best results.

Dermatologists recommend early treatment of rhinophyma to help prevent the condition from progressing and becoming more difficult to treat. In the advanced stages, rhinophyma can cause difficulty breathing through the nose. It also is possible for the nostrils to collapse.

Other Surgical Methods

A 2003 paper; New surgical adjuncts in the treatment of rhinophyma: the microdebrider and FloSeal details a novel technique using a standard microdebrider followed by a haemostatic sealant to eliminate bleeding.

Now Over to You

What have you found to be useful in your battles with a red nose ? Please help your fellow rosacea sufferers by leaving a comment below.

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Recalcitrant rosacea successfully treated with multiplexed pulsed dye laser.

J Drugs Dermatol. 2007 Aug;6(8):843-5, Larson AA, Goldman MP

There are few treatments that address both papulopustular and telangiectatic components of rosacea. We present a case of rosacea that was unresponsive to treatment with antibiotics. We report the novel use of a new laser technology, the multiplexed laser, for treatment of both papular and telangiectatic rosacea.

The author has kindly sent a copy of the paper, so if you would like to read a copy, let me know. Here is a quote describing the laser used in the report.

Cynergy MultiPlex (Cynosure, Westford, MA) is a new technology combining a long-pulse PDL with a 1064-nm Nd:YAG laser. The 595-nm wavelength targets the yellow absorption peak of oxyhemoglobin. It is thought that the laser also stimulates the ferrous iron (Fe2+) molecule of heme to ferric iron (Fe3+), converting hemoglobin to methemoglobin. Methemoglobin is unable to bind oxygen, and is a greenish-black pigment. The Nd:YAG laser treats this new chromophore more effectively than hemoglobin. Sequential lasering with this combination is thought to be more effective than either laser alone in the treatment of vascular lesions. It not only treats a broader spectrum of vascular lesions at various depths, but also decreases the number of treatments needed.

Disclosure: Dr. Goldman serves as a consultant for Lumenis, Cynosure,
and Dusa Pharmaceuticals but has received no specific funding
for performing treatment or writing this article.

The patient showed a 50% improvement of papules and telangiectasia after one treatment with Cynergy PL. The paper ends by saying that one of the advantages of this combination laser is less need to treat at purpuragenic causing energy levels – i.e. it can offer less downtime compared to other Pulse Dye Laser treatments.

For more information on the laser, see Cynergy Vascular Workstation.

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The study participants were treated with IPL or PDL on one side of their face. I’m not sure that I would be keen to participate in such a study, so I feel grateful to them ! Hopefully they were offered full face treatments at the conclusion of the study, especially given that the study also confirmed that PDL/IPL was an effective treatment !

In the study, the researchers examined biopsies of 10 rosacea patients before and after five received PDL treatment and five IPL treatment for the presence of biochemical components previously associated with rosacea. Each patient received four monthly treatment sessions on one side of the face, with the untreated side serving as a clinical control.

Two of the interesting results from the study ;

Eight of the patients were also found to have elevated cathelicidins, natural antimicrobial agents linked in previous research to rosacea inflammation, and the level was reduced in three IPL- and two PDL-treated patients after treatment.

and

Before treatment the researchers found elevated levels of vascular endothelial growth factor (VEGF), associated with the development of visible blood vessels (telangiectasia), in five of the 10 rosacea patients. In four of these subjects — three in the PDL group and one in the IPL group — the level decreased after therapy.

We know that in 2007 the NRS awarded further grants to Dr. Richard Gallo, and Dr. Kenshi Yamasaki who will continue their research of how cathelicidins, one of the body’s own natural antibiotics, may play a role in the development of rosacea symptoms.

Further Reading ;

• NRS Blog: Beneath the Surface of Lasers
• NRS Blog: Is Rosacea Like an Allergy?
• VEGF and vasodilation
• retinaldehyde may reduce VEGF
• SPF-90 inhibits VEGF, IL-1a and MMP-1 induced by UVB radiation
• cathelicidins show allergic basis for rosacea ?
• Focus on cathelicidin and its role in rosacea
• IPL is excellent for rosacea
• pain, swelling and redness after pulse dye laser treatments
• pulse dye laser improves erythema