Welcome to Plastic Surgery Talk with Dr Stephen Mulholland, brought to you by SpaMedica.
Hello and welcome, Dr Stephen Mulholland here on Plastic Surgery Talk, welcome to our podcast series. Today’s podcast is on a very common problem, rosacea. Red, ruddy complected, inflamed skin. Extremely common and very few people know the best treatment. We’re gonna find out that, today.
So, what is rosacea? Rosacea is a clinical syndrome of a red, ruddy complexion. Arithmitous, red, ruddy complected skin with broken capillaries that can lead to dilated pores and acneiform eruptions. It’s inflamed and sensitive. It’s a whole spectrum, from just flushing and early redness in your 30s, to full blown rosacea, with acne breakouts, and dilated pores and sometimes even sebaceous hyperplasia, or overgrowth of the nose and rhinophyma. It’s a whole spectrum, but the underpinning of the disease, of the condition is inflammatory, red, ruddy complexion.
What is the treatment for rosacea? Well, there’s a lot of misconceptions, even in the medical community, and so there’s more the medical dermatologic model, which is let’s get rosacea under control, let’s treat the cause. The problem is we don’t know the true cause and etiology of rosacea.
Some consider it an inflammatory condition caused by a small microbial organism that lurks out in the depths of your skin, where the vasodilator apparatus is for that skin, and the inflammation causes vasodilation, the opening up of the blood vessels, and the redness and the inflammation continues. That is the infectious model of rosacea, and so, often a dermatologist will prescribe Metrogel, metronidazole topical gel to wear on your skin, put on your skin to try and kill these little organisms, or an antibiotic like doxycycline to control the acneiform eruptions, or the proliferation of proprium bacteria acnes in the sebaceous glands.
This antibiotic infective model for rosacea isn’t always effective, because many believe it’s not just due to an infection, or organisms and skin, but due to a hereditary condition, a vasodilation of the A/B shunts in your skin that open up because you have a genetic risk, and they lead to a redness, and then the redness leads to inflammation, the inflammation leads to changes in your pores and texture, and becomes a vicious cycle because of A/B shunt dilation genetic risk.
Others believe that it’s a reaction to sun exposure, sun damage and environmental toxins. Either way, my personal belief is, we have no clue what truly causes rosacea, so rather than try and treat the etiology, or the cause, we should try and treat the underlying pathology, which is dilated vessels, open vessels and try to close them off and get control of the redness and the inflammation. That should lead to a resolution of the sequelae, which is sensitive skin, dilated inflamed pores, acneiform eruptions and a red face syndrome that is socially stigmatizing, ’cause you have this red, ruddy face and people assume you’re a drinker.
You may not be a drinker, but you have the face of a drinker. What does the treatment involve? Selecting the best treatment options that treat the underlying condition. So, what is the treatment, after that long preamble, what is the treatment for rosacea? I think you go through the basic mechanisms of the dermatologic model, you try topical Metrogel, you try oral antibiotics, you try skin cleansers and toners that help cleanse the skin and try to get rid of the acneiform inflammatory component, and when that fails, as it often will, or not be a complete cure, you go to the “let’s treat the underlying physiology of it,” which is a vasodilation, so we want to close off the vessels that dilate and create the redness.
After 20 years of treating skin with rosacea, in my opinion, by far the most effective treatment is intense pulse light photo rejuvenation or a photo facial. How does IPL, intense pulse light photo rejuvenation work for rosacea? Well, first, intense pulse light is a xenon flash lamp, a flash of light is released from this laser light device, coming out of an applicator that you apply on the rosacea skin. The flash of light, like laser hair removal, goes into the skin, and it injures the lining of small blood vessels, enough injury to cause a thermal inflammation, that closes off the blood vessels.
So, if we can close off thousands and thousands of these blood vessels, in aggregate, we’re gonna get less red. If we get less red, we get less vasodilatation, less inflammation, less inflammation, less acneiform eruptions, we don’t get dilated pores, we don’t get rhinophyma and our skin isn’t as sensitive. So, to treat rosacea, we need to treat the underlying problem of many, many, many dilated vessels that need to be closed off, and the intense pulse light, or IPL photo rejuvenation treating the entire face, the cheek, the chin, the nose, is the best way we know of in aesthetic medicine to control, not cure rosacea.
Who’s a good candidate for IPL photo rejuvenation, for the treatment of rosacea? Well, patients with rosacea, so you need to have red, ruddy complexion, a red flusher, blusher type of patient, acneiform eruptions, dilated pores, a constellation of syndromes, in a spectrum from flushing and redness to inflammatory rosacea. You need to be a patient who is medically well, you need to be a patient that doesn’t have a pacemaker, ’cause the laser can interfere with the pacemaker. You cannot be pregnant, you can’t have any contraindication to treatment and you need to be realistic.
We cannot cure your rosacea, we can improve the appearance of your rosacea, but we can’t get rid of 100 percent of it, only improve it significantly. How much improvement? Between 50 and 75 percent, after a series of IPL photo rejuvenation treatments. How is IPL photo performed on rosacea? Well first, we conduct a consultation, make sure you’re a reasonable candidate, you have expectations that are achievable, and you don’t meet any of the contraindications. Once you’re a good candidate, then we do the treatment.
The treatment consists of applying topical anesthetic cream, using a little bit of laughing gas, called Pronox, and then we flash a light device, a photo facial light device, an applicator is placed on the skin, there’s a little interface of ultrasound gel, and we flash light into your skin. The flashes of light contain the IPL energy. Photons of energy that are specifically targeting the redness. We treat your entire face, it might take 25, 30 minutes, treat the entire face. We spend a little more time on the red, ruddy complected areas, but we treat your entire face.
We do a series of those treatments, once every three to four weeks, and we do five to nine treatments. So it might take between five and nine months to finally complete the program, and after a series of treatments, between five and nine treatments on average, you get 50 to 75 percent reduction in redness, inflammation, irritation and skin rejuvenation, the appearance of smoother, less porous, less inflamed skin.
That’s our goal. 50 to 70 percent reduction in redness, smoother skin, less porous skin, skin that’s not as prone to acneiform eruptions and then we need to stay on maintenance to protect your investment. Is there maintenance required after your series of photo facial rosacea treatments? The answer is absolutely yes. If you stop doing your IPL photo facial treatments for your rosacea, and you wait let’s say, two years, all that redness will creep back into the skin. You’ll have a complete recurrence of your original pathology.
I tell patients, rosacea and melasma, brown discoloration is like having diabetes of your skin, or hypertension of your skin. If you stop the insulin, the diabetes comes back, if you stop your anti-hypertension, your blood pressure skyrockets. So, you can have control with a photo facial series. After that let’s say five to nine treatments, you have 75 to 80 percent reduction, you do a single treatment every three months for the rest of your life to keep that rosacea under control. Never cured, but under control.
A maintenance program, three to four treatments a year for the rest of your life, to get an 80 percent plus reduction in the appearance of rosacea and the symptoms of rosacea. Now, let’s say you’ve done your entire series, five to nine treatments, it’s taken you six, seven, eight months to finish, you get a nice improvement, 50 to 75 percent reduction. How long will that result last?
The answer is about two years. If you don’t do a single maintenance treatment, and you had bad rosacea to begin with, you can expect your complexion to deteriorate back to what you had it in two years. If you just do some simple maintenance treatments, one to four treatments a year, you should keep that rosacea at bay and under control. If you continue with daily treatments, you’ll never get that rosacea back and you’ll have in essence, a cure. A cure that’s modulated by your commitment to coming back for maintenance to protect your investment.
After you’ve done your photo facial treatments, you need to have a few post treatment care policies and approaches. Number one, we don’t recommend sun exposure for two days after, your skin is quite sensitive. Number two, you would avoid heavy exercise and working out that day, ’cause your face is a little inflamed. Number three, you need to be very cautious on what you put on your skin, any time with rosacea, ’cause it’s quite sensitive, the skin.
But you don’t want to be too aggressive with your medical skin care, nothing too astringent, nothing too inflammatory because your skin’ll be very sensitive and it takes often five to seven days for the skin to return to relatively normal after a good photo facial rosacea treatment.
I get a lot of questions when I do workshops around the US about a photo facial. How can such a simple procedure be so painful? ‘Cause it does cause discomfort. You have to remember, you have this release of light. The light hits the skin, it’s absorbed by the blood vessel, and there’s a ton of blood vessels in rosacea, and it creates heat, and the heat releases energy, ambient radiant energy that stimulates the pain fibers in your skin. So, too much heat can give you the sense your skin is burning, so it can be uncomfortable.
When offering photo facial treatments in your clinic, if you have a lot of patients with rosacea, and a lot of red and inflamed patients, you’re gonna need to offer topical anesthetic cream, plus use some type of medication like laughing gas, which is given to patients about 15 minutes before and then we do the treatment. Of course, they feel quite happy about life, and so nitrous oxide, topical anesthetic cream and an air chiller, a cool chiller are the best ways to give a nice, comfortable treatment that makes the whole rosacea IPL photo facial acceptable, because the discomfort is moderate.
Are there any significant risks with IPL photo facial for rosacea? The risk is yes. In the course of treatment with intense pulse light, we may overestimate the amount of energy we need in an area, and one of the pulses could cause a blister, and the blister could lead to a scar. Therefore you want to be very cautious about your settings and your parameters, make sure you’ve got a good informed consent booklet signed by the patient, where they understand the risks and the benefits of this treatment, and then you just execute a good photo facial treatment.
Of course, the number one risk is there’s too much energy applied in any given area, and you can lead to not just an improvement in the redness, but a burn or an injury that leads to a scar. The closer that that scar gets to the center of the face, the more visible it might be. So, we want to be very cautious, conservative settings, have a physician or non-physician doing these treatments that has a lot of experience and remember, even though it’s just IPL photo rejuvenation, it’s still one of the most common causes of a laser side effect. More common than hair removal, more common than pigmented lesion removal.
So, pick a good center with a [inaudible 00:13:06] got lots of treating rosacea and ensure that you have proper skin care going in and out of each treatment and that if it feels aggressive and it’s causing burning during the treatment, complain to your physician. “Ow, that really hurts. It’s burning my skin.” It’s very important that you give feedback, otherwise they’re gonna treat basically just a computer, rather than a patient.
Rosacea is a wonderful treatment for a red, ruddy complexion and the anti-aging, more youthful look, and it works great in combination with Botox for your frown lines and soft tissue fillers to the underline and the cheekbones. The use of topical skin care cream, like Universe Skin or Obagi RealSelf has a number of different skin care regimes that work very nicely in conjunction with rosacea, but you have to acknowledge and understand, the skin of these patients is always gonna be very, very sensitive. You need a cautious skin care line that does not overdo it, or you can have patients complaining of red inflamed skin because they’re on a skin care that causes worsening of their red inflamed skin.
What is the cost for an IPL photo rejuvenation, for the treatment of rosacea? In general, at our clinic, it costs $750 for a full face photo rejuvenation photo facial. You can add the neck to that, that’s slightly more, perhaps we’re in the $1200 range, and you need to do a treatment about every six to eight weeks, until you’ve plateaued on the treatment expectations, which is 50 to 80 percent improvement in the appearance of that red, ruddy complexion after a series of treatments and requiring one maintenance every three months, starting in Year Two.
Thank you very much for joining me again, Dr Stephen Mulholland on Plastic Surgery Talk here in Toronto, Canada. Our podcast this week was on rosacea. Red, ruddy complected skin and the treatment, diagnosis and management of rosacea. If you found this podcast interesting, entertaining and helpful, by all means, subscribe, share and comment.