IPL: Wave of the future in rosacea therapy

Too often underused, M.D. says.

Special Report
Dermatology Times

Aug 1, 2006
By: John Nemec

New York — The brightest future for rosacea patients may involve intense pulsed light (IPL) therapy, Harvey Jay, M.D., says.

Although it has been available as a treatment option for about 10 years, the therapy is underused and too often misunderstood, according to Dr. Jay, clinical assistant professor of dermatology at Weill Cornell Medical Center, here.

"One of the problems many physicians have had with IPL is that there are so many options," says Dr. Jay, a board-certified dermatologist in private practice in Manhattan. When properly used, he notes, IPL treatment causes minimal discomfort and no downtime for the patient.

Many practitioners fail to realize the importance of treating the range of signs and symptoms associated with rosacea, Dr. Jay points out.

"Aside from the rhinophyma, which can be treated with lasers, there are four areas to address: the pimples, the erythema, the flushing and the burning, stinging and/or tingling," he explains.

Awareness lags
The pimples — and redness associated with them — can be treated by topical medications and oral antibiotics. The general erythema, however, does not respond well to these treatments, in Dr. Jay's experience. The redness, along with the pimpling, can be treated successfully with lasers or IPL, he says, but it appears that awareness of this is not widespread among patients and even physicians.

"It's amazing how many patients come to me because their doctors, including dermatologists, told them there's no effective treatment for the redness," Dr. Jay says.

One such patient is a woman who hadn't held a job for several years because of rosacea with intense facial erythema. She also had severe flushing with burning and stinging. Her condition improved remarkably with IPL treatment (see photos).

The flushing, a response to a variety of stressors, can be debilitating for rosacea sufferers, especially teachers, managers and anyone in the public eye.

Dr. Jay has discovered that IPL treatment is also effective in controlling the flushing; he has used it successfully toward that end for the past six years. IPL likewise can reduce or eliminate the burning, stinging and tingling experienced by many rosacea patients.

Dr. Jay currently uses the Vasculight IPL system (Lumenis), which is both powerful (up to 90 J/cm2) and flexible.

"The newer machines, paradoxically, tend to be simpler and cheaper because the market has shifted more toward the spa and the nondermatologist," he observes. "The companies say that some of the high-end newer units are 'flat-topped,' meaning there is an even distribution of light emitted. My unit, however, is also flat-topped; I tested it myself with an oscilloscope."

His patients usually see improvement in their rosacea within a week or two of the initial IPL treatment, he says. Typically, maximum benefit is achieved in four to six treatments spaced three to four weeks apart.

Easy does it
A current trend that Dr. Jay has observed is aggressive treatment of rosacea, whether with lasers, IPL or combination therapy. He believes this approach can exacerbate rosacea patients' discomfort, as they almost always have sensitive skin.

"Usually, when I have tried to be more aggressive with treatments, the patients have experienced more inflammation and their symptoms have flared," Dr. Jay says. "I believe inflammation is an integral component of rosacea, which may be manifested by dilated blood vessels and redness."

With customized IPL settings, patients usually experience no pain, and there is bruising in less than 1 percent of cases, he reports.

Lasers, too, can be effective in treating the various components of rosacea, Dr. Jay adds, when they are used appropriately. Because lasers are more specific in terms of wavelength, however, practitioners may need more than one type, depending on the size of the vessels and their cutaneous depth. "You're not going to want to use a 532-nm laser, for instance, on a darker-skinned person because you might affect the pigment near the skin's surface," he notes.
Spa vs. medical office
As for the trend toward nonphysicians treating rosacea with IPL in spa settings, Dr. Jay points to the inherent dangers of misdiagnosis and inability to handle complications because of a limited understanding of cutaneous physiology.
He administers IPL treatment on all his patients himself instead of delegating the task to a technician.
A number of dermatologists who use photodynamic therapy (PDT) for acne or other indications have been using it to treat rosacea as well. Dr. Jay has not experimented with it.
"Many rosacea patients are very photosensitive, and I think there's a significant association between rosacea and a history of light or sun exposure," he says. "I'm concerned as to how the (5-aminolevulinic acid) gel gets deeper into the skin and blood vessels, and also concerned about the inflammation it may cause in patients whose skin is already sensitive and inflamed."
More study is needed, Dr. Jay says, not only to compare effectiveness of the various therapies and their mechanisms of action, but also to improve understanding of the etiology and physiology of rosacea itself.

Disclosure: Dr. Jay reports no conflicts of interest with regard to products mentioned in this article.