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Successful Management
of Rosacea with Lasers
Specialists share insights to help dermatologists and patients get the most from laser therapy for rosacea.
By Paul Winnington, Editorial Director
Though a novelty just a few years ago, the use of ically uses the Gemini (Iridex) with a 10mm spot, lasers to treat rosacea has become mainstream.
allowing her to “rapidly treat the entire face. You can In fact, when it comes to managing rosacea, treat the whole face in less than five minutes.” The “laser really should be a first-line therapy,” says pulsed dye laser (585-595nm) with a 10-12mm spot Arielle N. B. Kauvar, MD, Founding Director of New size or IPL are other options for diffuse erythema. York Laser and Skin Care and Clinical Associate Lasers can eradicate background erythema or Professor of Dermatology at New York University telangiectases for a better appearance and reduction School of Medicine. Unlike available medications in symptoms, including decreased sensation of that are not particularly effective for reducing red- warmth with flushing and a reduction in acne-like ness or eliminating telangiectasia, light energy in the lesions. Targeting of underlying vasculature provides 500-600nm range specifically targets erythema and long-lasting but not permanent effects, Dr. Kauvar says. Patients should expect to undergo maintenance Despite the ease and availability of laser treat- ment, it may not be a good fit for every dermatology As noted, Dr. Kauvar does not view laser therapy practice. At the same time, laser therapy for rosacea as a second-line intervention for erythema associated may actually offer a reliable and practice-friendly with rosacea, therefore her patients need not under- entrée into the field of laser therapy. Below, special- go a trial of topical or systemic therapy prior to ists offer tips on laser selection, patient education,and adjunctive measures to ensure best results. Take-Home Tips. Laser and light sources (KTP, PDL, IPL) effectively
reduce erythema, remove telengiectases, and reduce symptoms of
Targeting Rosacea
flushing and blushing with a series of treatments. Laser therapy can To treat individual telangiectases, Dr. Kauvar uses also improve photodamage, sun spots, and pigmented scars.
the 532nm KTP laser, which offers various spot sizes, Lifestyle modification (regular and proper sunscreen use, exercise, to trace out vessels. Typically, she uses a 2-3mm spot stress reduction, reduced alcohol and caffeine consumption, etc.) is size to treat individual vessels and says she achieves essential to therapeutic success. Standard adjunctive therapies good results with two to three treatment sessions. (topicals and oral) may be indicated for the papular/pustular More diffuse redness consistent with flushing and component of rosacea. Cosmeceuticals can help to reduce erythema, blushing will also respond to the 532nm KTP laser,though a larger spot size is indicated. Dr. Kauvar typ- repair the epidermal barrier, and improve photodamage. ● 38 | Practical Dermatology | January 2010
Lasers for Rosacea
receiving laser treatment. As a practical matter, how-ever, she observes that many patients have tried stan- Some Tips on Laser Adoption
dard treatments in the past with suboptimal results.
Before offering laser therapy for rosacea in your practice, Standard treatments may be useful to reduce or pre- vent the papular/pustular component of rosacea in • Go to laser courses and view live demonstrations.
prone patients even after laser treatment. • Get hands-on, in-office demonstrations involving your patients.
In addition to improvement of erythema and • Consider renting the specific laser you intend to purchase for a telangiectasia, any of the lasers or light sources used for rosacea—KTP, PDL, IPL—are also absorbed bypigment, allowing for treatment of brown spots, sundamage, and pigmented scars. KTP can also be used lesions with no downtime and no purpura, she for melasma, and Dr. Kauvar notes that treatment provides an improvement in overall skin texture and Before initiating laser therapy, patients must may help reduce the appearance of large pores.
understand that achieving optimal results will take Many patients, therefore, receive full-face treatments time, Dr. Downie says. “I ask patients, ‘How long did and may even receive treatment of the neck and it take you to get this red?’ and I explain that it’s also chest for a comprehensive cosmetic effect. going to take some time to reverse that damage,” she For patients with more advanced disease, infrared says. She generally tells patients to expect to undergo lasers can be used to target sebaceous hyperplasia, six to 10 or more treatments before seeing satisfacto- while management of rhinophyma requires a resur- ry results, although she says the range may actually facing laser, such as a CO2 or erbium. Aside from be from three to 20 treatment cycles, depending on other surgical procedures, there are no other treat- the individual’s initial condition and response to treatment. To help patients understand the benefits Dr. Kauvar notes that rosacea worsens with age and realities of laser therapy, Dr. Downie directs and cumulative sun exposure, therefore many them to the National Rosacea Society website patients present with common cosmetic concerns (rosacea.org), which she says is very informative and associated with photodamage and aging. As much as provides before and after images for patient review.
laser therapy can address these various concerns, it is “Patients very much push to go to lasers for a suitable choice for many rosacea patients. Addit- rosacea,” Dr. Downie observes, adding that treatment ional cosmetic interventions, such as neurotoxins and has benefits such as new collagen development, fillers, may also be of interest to these patients. Sun reduction of fine lines and wrinkles, and evening of protection and avoidance strategies, including use of a tone, in addition to removal of broken vessels and broad spectrum sunscreen, are essential for all background erythema. However, she warns, tradition- rosacea patients to help prevent further cutaneous al therapies and lifestyle modification both remain damage and prolong the effects of treatment.
important for her patients. “The first thing patients “Lasers are a huge part of my treatment of must do is use hypoallergenic, fragrance-free sun- rosacea,” acknowledges Jeanine B. Downie, MD, block at least SPF 30 daily,” Dr. Downie says, adding Founder of image Dermatology in Montclair, NJ.
that all patients regardless of ethnicity or skin tone However, she stresses that laser therapy is one must reapply sunscreen every two hours. She recom- part of an overall patient management approach.
mends MD Forte or Alyria sunscreens, which tend to Among the lasers she uses to treat rosacea are the rub in very well and be cosmetically acceptable for Vbeam Perfecta (595nm PDL, Candela), the Lyra multiple skin types. “If they’re not willing to use sun- (1064nm Nd:YAG, Iridex) and Aura (532nm KTP block, their rosacea is just going to get worse over Laser, Iridex). All three lasers are able to treat ves- sels, background erythema, and brown pigmented Adjunctive topical prescription therapies to consid- January 2010 | Practical Dermatology | 39
Lasers for Rosacea
er are metronidazole 1% (Metrogel, Galderma) orazelaic acid gel 15% (Finacea, Intendis), according to Update on Laser Treatment of Acne
Dr. Downie. She says she tends to favor azelaic acid, Generally, lasers are effective for acne that is papular/pustular, even though, “it can be a little more irritating.” rather than characterized by cysts, blackheads, and whiteheads.
Adding an oil-free facial moisturizer helps improve Lasers are also useful for acne-associated hyperpigmentation tolerability, she says. For patients interested in cos- (when the skin becomes slightly darker than one skin shade), meceuticals, Dr. Downie recommends Revale Skin according to Dr. Downie. Laser therapy likely provides benefit Intense Recovery (Stiefel) with 1.5% coffeeberry,which she says helps to reduce erythema. Incorp- through multiple mechanisms, including decreasing P acnes orated antioxidants help improve tone and texture, colony counts, reducing erythema, and decreasing hyperpigmen- and the formulation supports improved barrier func- tation. Combined with standard topical therapies, laser therapy tion, which is important in rosacea.
offers important benefits for most patients with papular/pustular Oral treatment options include anti-inflammatory acne, and Dr. Downie says about two-thirds of her patients are dose doxycycline (Oracea 40mg, Galderma), standard doxycycline (Doryx 150mg, Warner-Chilcott or Adoxa For patients with primarily papular/pustular acne who develop 150mg, PharmaDerm), or low-dose minocycline occasional acne cysts, intralesional injections are indicated. For patients with acne that has a significant cystic component, lasers Lifestyle modification is essential, including more usually are not first-line treatment options, but they can be useful exercise and less coffee, wine, stress, and sun expo- for patients who refuse systemic antibiotics or isotretinoin, Dr.
sure, says Dr. Downie. Some rosacea patients resist Downie says. Fraxel re:store (Fractional CO2, Thermage) may be exercise, arguing that it causes them to flush.
appropriate for patients with cystic acne scarring, and Dr. Downie Drinking ice water throughout a workout helps to“trick” the baroceptors that mediate blood pressure says that she does not hesitate to treat scarring in patients with and will minimize flushing, Dr. Downie notes. With active acne. Having a personal history of bad but non-scarring time, patients will develop tolerance to exercise and acne, Dr. Downie says she understands the effect it can have on be less prone to flush and blush with exertion. If patients. “I don’t want patients to have to get worse while waiting needed, advise patients to schedule time for relax- for cysts to resolve,” she explains. So she treats aggressively.
ation in efforts to reduce stress. Explaining to Typical skin care following fractionated resurfacing includes patients the interaction of adrenal glands, endoge- Biafine (Ortho-Dermatologics) and a hydroquinone. Because nous hormones, cortisol release, and stress can help these can be irritating for patients with cystic acne, Dr. Downie them recognize the importance of stress reduction usually decreases the application of Biafine and incorporates a and encourage compliance with relaxation. strong topical retinoid, such as tazarotene (Tazorac, Allergan).
Treating active scarring acne is necessary not only to help A Nice Place to Start
reduce scar formation but because of other important effects. As While laser therapy for rosacea is quite effective and Dr. Downie explains, when the patient feels he or she is “doing Dr. Kauvar says it is “extremely satisfying” to be ableto provide patients treatment, she says it may not be something” about scarring, he or she feels more in control, which a good fit for all practices. “Look at your practice may lead to decreased stress hormone and possibly an overall demographics,” she suggests. “If a large component better sense of the self. When the patient feels better, he or she of your practice includes individuals with rosacea, this could be a nice place to start in terms of adopt- Because patients may have a tendency to underestimate ing laser treatment modalities.” As a final pearl to improvement, and because results may be subtle, Dr. Downie dermatologists, Dr. Downie recommends aggressive recommends taking images before starting laser therapy in any treatment of spider hemangiomas, which can be pre- patient and taking additional photos after each treatment.
40 | Practical Dermatology | January 2010

Source: http://www.hitechlasers.co.za/pdf/Irridex%20News%20article%20January%202010.pdf