Laser and Light Sources for the Treatment of Rosacea

Rosacea is a chronic, inflammatory disorder characterized by persistent erythema, telangiectasia, papules, pustules, flushing, and phymas.^1,2 Rosacea primarily affects the facial skin of fair-skinned individuals, but it has also been reported in darker skin types. Beyond the appearance of rosacea, it has significant emotional implications and commonly affects quality of life and may result in depression or anxiety.³ Although no cure for rosacea exists, a combination approach to management can provide effective improvement. In general, medical management with topical and oral medications is reserved for papules, pustules, and flushing. Persistent erythema, telangiectasia, and rhinophyma are amenable to treatment with lasers and light sources.

Laser treatment of rosacea is based on selective photothermolysis of blood vessels.⁴ Intravascular hemoglobin absorbs the photon energy, which is then converted to kinetic energy. Subsequent heat diffusion to perivascular collagen denatures the vascular wall components, leading to resorption of the vessels and clinical improvement in erythema. Traditionally, potassium-titanyl-phosphate (KTP) and pulsed dye lasers (PDL) are used to treat the erythematotelangiectatic component of rosacea, but longer wavelengths such as the 1064-nm neodymium-doped yttrium aluminum garnet (Nd:YAG) laser are sometimes used for deeper penetration.

When planning your laser treatment, it is important to differentiate between the different vessel morphologies, ie, diffuse redness vs distinct telangiectasia. Diffuse redness is made up of vessels with a smaller diameter and should respond best to a slightly shorter pulse duration. Distinct telangiectasia have larger diameters and may require a longer pulse duration for an effective treatment.

Initial counseling of patients is key to set up proper expectations. Laser treatment of rosacea generally requires three to five treatments approximately a month apart with maintenance treatments every 6 to 12 months. Typical side effects of laser treatment include increased redness, swelling, and potential bruising. Downtime is easily tolerated and generally takes about 1 week to heal. Patients may use makeup during this time if desired.

PDL treatment has been well established to improve erythema and quality of life in patients with rosacea.⁵ Ultrashort pulse durations may result in purpura and should be avoided in patients with  cosmetic concerns, if possible. Longer pulse durations decrease the risk of purpura, providing a more cosmetically acceptable and effective outcome. KTP laser treatment has a lower risk of purpura due to its longer pulse durations and may be preferable to patients due to the lower risk of side effects and decreased pain profile.⁶

Regardless of the wavelength used, some tricks to enhance efficacy maximize hemoglobin available for absorption. One can accentuate erythema by rubbing the face aggressively with rubbing alcohol while cleaning, positioning the patient in Trendelenburg position, or keeping the room at warm temperatures. Increasing skin temperature maximizes hemoglobin and increases the chromophore for laser absorption.

Alar telangiectasia generally require multiple laser treatments and can be more difficult to resolve. The temptation lies to use the 1064-nm Nd:YAG laser, which has a deeper penetrating wavelength and may be more effective in their clearance. I caution the use of the 1064-nm Nd:YAG lasers for the treatment of alar telangiectasia because there have been several reports of atrophic scarring due to the high absorption of oxyhemoglobin over deoxyhemoglobin.⁷ This selectivity of arteries over veins increases the risk of atrophic scarring, particularly in the alar region. It is prudent to use more superficial wavelengths, such as PDL and KTP, as well as to warn your patients in advance that it may require additional treatments to clear alar telangiectasia.

For additional efficacy, one might consider a topical adjunctive therapy including brimonidine gel (an α-adrenergic agonist) or oxymetazoline hydrochloride cream (an α_1A-adrenoreceptor agonist) to improve the erythematous component of rosacea. These topical therapies are not effective for the telangiectatic component of rosacea, which is only improved with laser and light sources. It is important to have patients stop these topical therapies at least 3 days prior to laser treatment since their effect is to temporarily constrict blood vessels which may render the laser less effective.

Ocular rosacea is present in about 50% of rosacea patients.⁸ While it is best managed with eyelash hygiene and medical management, there have been reports of intense pulsed light (IPL) for the improvement of ocular rosacea symptoms.⁹ Symptoms improved after treatment of periocular skin (from tragus to tragus and from the maxillary process of the zygomatic bone to the inferior orbital rim¹⁰) using an IPL filtered to emit green-yellow light pulses. The mechanism of action is thought to be due to inhibition of the propagation of inflammatory mediators to the meibomian glands.¹¹

Laser treatment of rhinophyma is possibly one of the most life-changing results we can provide as laser surgeons (Figure). Various techniques to improve contour include carbon dioxide and erbium laser in addition to radiofrequency and sculpting with a scalpel. In general, this is a one-time treatment. However, it is associated with prolonged downtime given the aggressiveness of the treatment.

As a laser surgeon, rosacea is one of the most common conditions that I treat. With proper counseling, it is a home-run treatment every time and a nice service we can provide to improve our patient’s quality of life.

Dr Ortiz is director of laser and cosmetic dermatology and associate clinical professor in the department of dermatology at the University of California, San Diego.

Disclosure: The author is a consultant for Cutera.

References
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