Active Ingredient: Isotretinoin
Lasers and lights Many lasers have created a paradigm shift in the treatment of erythema and telangiectasias associated with rosacea. The older generation of argon, copper bromide, and krypton lasers paved the way for new lasers and lights developed specifically for cutaneous vascular lesions with more precision to minimize such side effects as hypopigmentation, atrophic scars, and recovery time.
Pulsed dye laser PDL historically emitted light at 577 nm and more recently at 585 nm or 595 nm, all wavelengths that closely correspond with the absorption peak of oxyhemoglobin and thus target superficial vasculature.
In addition, biopsies taken before and 3 months after treatment were analyzed immunohistochemically for changes in substance P, calcitonin gene-related peptide, and vasoactive intestinal polypeptide, all of which are neuropeptides implicated in microvascular pathophysiology.
Dermal papillae demonstrated a statistically significant reduction in the number of substance P-positive nerve fibers; however, no effect was seen on either vasoactive intestinal polypeptide or calcitonin gene-related peptide immunoreactivity.
This finding highlights substance P as a potential key player in the pathophysiology of the vascular changes prominent in rosacea and responsive to PDL therapy.
Intense pulsed light IPL has been shown to be applicable in various clinical settings, including rosacea, port wine stains, disseminated porokeratosis, seborrheic keratosis, sarcoidosis, and hypertrophic keloid scars.
Most IPL systems provide a large spot size, reducing patient discomfort, increasing efficiency of treatment, and enabling deeper light penetration.
When used appropriately, IPL appears to provide impressive results in various settings with a relatively negligible side effect profile.
Taub et al tackled the persistent background erythema often remaining after effective targeted therapy of telangiectasia in patients with ETR.
The electro-optical synergy parameters were complex, with a combination of short pulses 13 msec light and 80 msec radiofrequency performed horizontally and long pulses 12 msec light and 85 msec radiofrequency performed vertically.
Outcome measures of erythema and telangiectasia were assessed by clinicians comparing before and after photographs in addition to self-assessment scores. Significant improvement was achieved in both erythema and telangiectasia assessed by both physicians and patients at all follow-up intervals.
Notably, patients reported significant improvement in flushing, one of the most psychosocially challenging disease manifestations.
Of note, IPL 560 nm filter has been compared with nonpurpuric 6 msec PDL in a head-to-head, randomized, controlled, split-face trial, and it was found that both treatment modalities demonstrated similar efficacy in improving erythema and telangiectasia in 29 patients with ETR.
Emitting light twice the frequency of Nd: YAG, KTP interacts with superficial chromophores, making it quite useful for superficial vessels and with less healing time.
Some recommend cooling the skin with chilled water-based gel and utilizing post-treatment ice, basing each treatment session off an endpoint when vascular lesions appear grayish and are no longer readily visible.
Twelve weeks after one to two treatments, PDL resulted in an average telangiectasia improvement score of 3. KTP has also be studied against IPL, with clinical improvements demonstrated for both, but with a significant skin temperature rise immediately after KTP as compared with no change in skin temperature after IPL.
Ablative laser therapy can be used to contour the deformed nasal shape by partial excision of the sebaceous follicle to the bases.
Despite transient swelling, erythema, and crusting which require longer healing times than nonablative lasers and risk permanent dyspigmentation, textural changes, and scarring, the ultimate results can be cosmetically and psychosocially life-changing in just one or two treatments Figure 8.
Figure 8 Before A and immediately after B continuous wave fully ablative carbon dioxide laser treatment, and 2 weeks following C treatment for metaphyma enlargement of sebaceous glands on the forehead.
Notes: Dramatic improvement without any sequelae is seen in the areas of concern for this patient. Similar results are seen with rhinophyma using comparable methods.
Clinical challenges: combination therapy and managing erythema in rosacea Since rosacea is a chronic inflammatory condition, it is uncommon for a single treatment to effect a permanent cure, and many frequently fall short of dramatic improvement.
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