Laser and light therapies for acne rosacea

Journal of Drugs in Dermatology,  Jan, 2006  by Kimberly J. Butterwick,  Lorren S. Butterwick,  Amy Han

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Abstract

Acne rosacea is a multifactorial, somewhat mercurial disorder that can be a challenge to control with standard pharmacologic agents. Laser and light sources have been increasingly utilized, particularly for control of the generalized erythema, flushing, and telangiectasia of rosacea. This paper will review the clinical studies presented in the literature specifically treating patients with rosacea. Long-pulsed dye lasers and intense pulsed light devices can offer patients effective treatment without the purpura of short-pulsed dye lasers. Long-term efficacy has not been studied but maintenance therapy may be necessary to control the vascular manifestations of this disease.

Introduction

The typical age of onset of rosacea is 30 to 50 years old and it occurs more often in those of northern and western European descent with a fair complexion. In a Swedish survey, it was estimated that females are affected more than males by a 3:1 ratio. (1)

Rosacea is a complicated inflammatory disease of the skin characterized by both vascular and acneform components with the cheeks and nose most commonly involved. It may also commonly involve the chin and forehead, and less often nonfacial regions such as the neck, ears, and scalp. Clinical manifestations may include transient erythema, persistent centrofacial erythema, telangiectasia, papules, and pustules. In severe cases, granulomatous changes and lymphedema may lead to the development of rhinophyma. Other secondary symptoms are burning and stinging, ocular manifestations (blepharitis and conjunctivitis), plaques, and a dry appearance. Four subtypes of rosacea have been recently introduced by the National Rosacea Society: erythema-totelangiectatic, papulopustular, phymatous, and ocular (2) (Table 1). Patients may exhibit features of more than one subtype simultaneously.

The etiology of rosacea is not fully understood. There appears to be a genetic tendency but other factors have been implicated in the mechanisms of this disease. Some suggested causative agents include Helicobacter pylori bacterium (3,4) and Demodex folliculorum, (5) but true causal relationships have not been clearly identified with these or any other infectious agent. In those with erythemotelangiectatic rosacea, the disease is exacerbated by exposure to caffeine, alcohol, spicy foods, emotional stress, exercise, and extreme temperatures. Wilkin et al demonstrated that rosacea patients blush longer and faster after drinking warm liquids than people who do not have rosacea. (2) The mechanism of this apparent vascular hyper-responsiveness is unknown. In addition to vascular dysfunction, disturbances in inflammatory and immunomodulatory processes have also been recognized in this disease. Histopathologic studies suggest inflammation of the pilosebaceous follicle may play a central role in the pathogenesis of rosacea. Powell and colleagues noted 31 of 33 biopsies of patients with papules and pustules showed evidence of folliculitis. (6)

Given the diversity in subtypes, symptoms, and in potential abnormal pathways in rosacea, it is not surprising that there is no uniform paradigm in treating this disease. Numerous medical treatments are available and must be tailored to subtype and symptoms. This paper will focus on laser and light therapies available for the first 2 subtypes of rosacea. Vascular lasers and light therapies are most effective for the erythematotelangiectatic subtype of rosacea (Figure 1).

Pulsed Dye Lasers

Laser therapy for acne rosacea has been utilized for the reduction of the telangiectasia and erythema seen in rosacea. Both short- and long-pulsed dye laser therapy with wavelengths of 585 or 595 nm have been examined for rosacea patients. These wavelengths correspond closely to the absorption peak of oxyhemoglobin (577 nm), and target superficial small vessels. Pulse durations from 450-[micro]s to 6 msec have been utilized in published rosacea studies (Table 2).

Lowe et al was the first to report the specific use of a vascular laser, the 585-nm pulsed dye laser, for treatment of rosacea in 1991. (7) Twenty-seven patients with a history of rosacea, refractory to either oral antibiotics or metronidazole gel, were treated with a 585 flash lamp pumped dye laser (Candela Corp SPTL--1) at 450-msec pulsed width and a 5 mm spot size. Within 1 to 3 treatment sessions, almost all treated areas improved to an excellent (10) or good degree (14) utilizing fluences of 6.0 to 7.5 J/[cm.sup.2]. In another prospective study by Clark et al utilizing the 450-msec pulsed dye laser (Candela Corp SPTL--1b, Wayland, MA) in 12 patients, a split-face controlled study demonstrated similar results with 50% reduction in erythema, 55% reduction in flushing, and 75% reduction in telangiectasia after an average of 3 treatments with fluences of 5.5 to 7.5 J/[cm.sup.2]. (8) A trend toward reduction in inflammatory lesions was also noted in this study. Purpura occurred in all patients lasting 7 to 10 days, post inflammatory hyperpigmentation occurred in half of the patients, and 2 patients had small macular atrophic scars. These findings were similar to Tan's study that used similar laser parameters with lower fluences. (9) Tan had fewer patients with post inflammatory hyperpigmentation (6/40) and no incidence of scarring. Lonne-Rahm conducted a study of 32 patients with rosacea, all with positive results from a lactic acid "stinger" test. (10) Three months after a single treatment with a 585-nm, 450-[micro]sec PDL utilizing fluences of 6.0 to 6.75J/[cm.sup.2], 24 of 32 patients had a negative stinger test and all but one had a decreased stinger test score. The authors concluded that laser treatment of rosacea has a clear medical benefit in the reduction in unpleasant symptoms of sensitive skin. A fifth study with the 585-nm short-pulsed dye laser (Candela Corp, SPTL--1, Wayland, MA), however, contradicted other studies, concluding that this laser was of limited value in the treatment of rosacea utilizing similar parameters of 450 msec and a mean fluence of 6.5J/[cm.sup.2] in 10 patients. (11)