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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Two subsequent studies have examined newer long-pulsed dye lasers for the vascular manifestations of rosacea, which have the potential to treat vascular ectasias without the purpura of the short-pulsed dye lasers. Newer generation lasers also incorporate cooling devices to cool the epidermis before, during, or after the laser pulse therapy enabling higher fluences while protecting the epidermis. Tan treated 16 patients with a 595-nm PDL (V beam, Candela Corp, Wayland, MA) with a 7-mm sport size, a 1.5-msec pulse duration, and fluences ranging from 9.5 to 11.5 J/[cm.sup.2] depending on tissue response for 2 monthly treatment sessions. (12) All patients experienced a significant improvement in their quality of life and a reduction in their degree of flushing and other symptoms. Despite this success, all patients experienced immediate, deliberate purpura as part of the chosen study design because gentler, subpurpuric thresholds had been shown to be less effective in earlier studies. Complications included transient hyperpigmentation (31.2%) and crusting (25%) and, as described earlier, postoperative purpura. Due to the high complication rate and prolonged down time, this treatment may not be the treatment of choice for the majority of patients, despite its efficacy. A second study with a long-pulsed dye laser by Jasmin utilized a 595-nm PDL (V Beam, Candela Corp) with subpurpuric pulse widths of 6 msec, a 7-mm spot size, and titrated fluences from 7 to 9 J/[cm.sup.2]. (13) Immediate purpura lasting only a few seconds was the treatment endpoint. Pretreatment cooling was achieved by cryogen spray for 30 msec. After one treatment, 2 of 12 patients had 75% improvement, 2 had 50% to 75% improvement, and 5 hand 25% to 50% improvement. There was no lasting post treatment purpura, and there were no complications.

Although subpurpuric PDL therapy with pulse durations of 6 msec or greater, will generally require more than one treatment (2 to 6) to substantially reduce the vascular manifestations of rosacea, in our experience, most patients will choose this option rather than undergo purpura, downtime, and increased risk of complications. When the primary target is the facial erythema of rosacea, larger spot sizes (10 mm) should be chosen to avoid reticulation. (7,14) Two to three laser passes may be required for optimal efficacy. For facial telangiectasia, effective treatment with a long-pulsed dye laser may require stacking of 3 to 4 laser pulses. (15) The endpoint should be vessel blanching or transient thrombosis. When stacking laser pulses, the laser surgeon may want to use lower fluences being careful not to damage or destroy tissue. If a plateau in response is noted with long-pulsed dye lasers, the 0.5-msec pulsed dye laser may then be utilized with expected purpuric sequelae. The smaller 40- to 60-mm vessels involved in flushing are expected to be more susceptible to this pulse width. (16) For these stubborn cases, or if patients have time for only one treatment, short-pulsed dye lasers are generally quite effective.