Many treatment options exist for the management of rosacea, but maintaining efficacy and clearance is a constant challenge. Often, effective treatment requires a multi-faceted approach to intervention. Laser and other light-based devices are among the many possible adjuncts to rosacea therapy and can be particularly useful in challenging cases. Recent years have seen a range of advancements in device technology, which has resulted in the potential for safer and more nuanced treatments for rosacea patients. Ahead, Michael H. Gold, MD, FAAD, Founder and Medical Director of Gold Skin Care Center in Nashville, TN, discusses the ways in which lasers can be integrated into care, the subtle differences between lasers, and how to use lasers to bridge the variety of medical and cosmetic aspects of the specialty.
Can you describe the evolution of the use of devices in the treatment of rosacea and how you see their role currently?
While medical therapy remains the standard of care in most centers, Dr. Gold notes that lasers and light sources are very useful for aiding in the treatment of rosacea. “We need to remember that part of the disease process is vascular in nature, and for this, lasers and light sources can be a wonderful adjunct to the medical therapy,” Dr. Gold observes. Combined with a good skin care regimen and perhaps other topical or even oral agents, lasers can offer great benefits. “Many of our patients find the benefits of this combination therapy being extremely effective in treating both the papular and vascular components of rosacea,” he continues. However, it's worth considering that the potential addition of lasers invites a different set of concerns from patients, mostly related to finances. “The major hurdle at this time for even more widespread use of these devices is that rosacea laser treatments are usually cash-pay versus insurance-pay for medical therapy.”
what are the differences among current lasers and which devices have you had the most success with?
“We have a wide variety of devices that work extremely well for rosacea,” notes Dr. Gold. He points out that most dermatologists might recommend a pulsed dye laser, given that they have the longest track record and most literature to support their use. “We know that using pulsed dye lasers are effective because they target blood vessels and capillaries and thus the redness associated with the disease,” Dr. Gold explains. He notes that the Syneron-Candela V-Beam Perfecta works very well and is considered by some to be the ultimate device in the pulsed dye arena. However, Dr. Gold observes that Cynosure's Cynergy can be equally effective. “The Cynergy device has the added benefit of using pulsed dye and 1064nm together, which can be advantageous for certain darker skin types.” Dr. Gold maintains that in the pulsed dye realm, both devices are very effective. “One is not necessarily superior to the other,” Dr. Gold says.
In addition to pulsed dye lasers, Dr. Gold notes that intense pulsed light (IPL) devices also work well. “IPL devices can perform many of functions, such as treating blood and pigment and also even rejuvenating the skin,” says Dr. Gold. They can be particularly effective in patients whose rosacea has been cleared but are left with pigment issues. In addition, the pulse structure does not vary as much with the newer devices and is considerably more sophisticated than older models, says Dr. Gold. “Instead of having a big pulse with lots of energy at the start of treatment and then dissipating, the pulse is much more even on many IPL devices currently, meaning they are much safer, as well,” he continues. “The Lumenis One was the first IPL device to introduce the square pulse, which used lower energy and resulted in more balanced and safer treatments.” Other effective IPL devices include the Sciton BBL, the Alma Harmony AFT, and the Lumenis M22, according to Dr. Gold.
Expect advancements to continue in the IPL realm, as well, as hand pieces and other add-on pieces may improve treatment outcomes. “Interestingly, Alma recently introduced the Dye-PL hand piece, a pulsed light source that covers 500 to 600nm, or 550 to 650, depending on the model. This has interesting potential, as it is almost like having a pulsed dye hand piece for the Harmony platform device, which we have not had before and may become very useful for our rosacea patients,” notes Dr. Gold.
What are some of the factors clinicians should consider when making a decision to use a particular device or light-based devices in general?
With the newer parameters on the pulsed dye lasers—nonpurpuric settings—downtime with these and the IPLs are very little, notes Dr. Gold. “There is mild discomfort with the actual treatment; nothing that anyone cannot tolerate.” However, it's important to note that, as with all lasers and light sources, these devices can cause adverse events with improper use. “Blisters, burns, hyper- and hypopigmentation, and scars can result when they are used by people not skilled in their use, which happens everyday,” says Dr. Gold. In an ideal world, only dermatologists and their trained staffs are using these devices, but many clinicians know this not to be the case. While dermatologists understand rosacea and know they are not necessarily curing the disease process, patients are usually seeing a number of different providers, from aesthetician to beauty spas, according to Dr. Gold. “Often, these providers do not understand the subtleties of the disease or operation of a device and only use a device in a single setting, which can result in a myriad of unforeseen consequences and adverse events.”
In light of these facts, Dr. Gold emphasizes the importance of a disease education process that physicians, staff, and even patients should undergo. “Dermatologists must come to grips with the reality that we are not the only gatekeepers of these treatments and should not take our knowledge and expertise for granted,” observes Dr. Gold. “Rosacea therapy is not a cut-and-paste job. But dermatologists have a unique opportunity to employ a number of options, including laser care, to secure the best results for each patient,” he continues. “And this requires education— on both how to use the device and the disease treated—for physicians, practice staff, and patients.”
do you see the direction of rosacea treatment headed toward a synergistic outlook, wherein multiple modes of therapy are incorporated?
According to Dr. Gold, clinicians who offer multiple therapeutic options to the patients they are caring for bring another level of care to the table. “If you only tell patients about a certain treatment for a disease when there are clearly other options out there, it does not allow the patients to have the options that they truly deserve,” explains Dr. Gold. “We always will tell our patients about medical treatments available, as well as laser and light source treatments we can offer. We explain the benefits of each, the potential risks, and the expectations associated with the treatments.” Dr. Gold notes further that he may not always start with lasers and light therapy, but it is nonetheless important for patients to be aware that it is an option and that it can be incorporated into therapy at any time.
Given the number of medical and aesthetic-based interventions available for rosacea, How do You educate patients about the range of cosmetic opportunities?
Using lasers and lights on medical conditions opens up the potential for the patient to learn about the other more cosmetic procedures you perform in your office, says Dr. Gold. “I try very hard to separate medical from cosmetic and will tell a patient we will deal with a cosmetic concern once we deal with the medical problem, but we are constantly educating them and they are learning more about what we do when they are having their laser or light procedure,” Dr. Gold notes. “This is good for all of us for future care.”
One of the initial steps in bridging the medical-cosmetic divide is to make sure that every room in your practice has information on various medical and cosmetic services that you provide. “Strategic positioning of educational materials for procedures such as toxins, fillers, and various others are essential in ensuring your patients are thinking about the wide range of opportunities they can pursue,” says Dr. Gold. In addition, staff members should be taught the “Oh, by the way,” moment at appropriate junctures in the exam room.
Dr. Gold reminds that if you don't educate your patients, they may not have any idea regarding the breadth of services dermatologists can provide. “I am amazed to hear people say, ‘I didn't know dermatologists did Botox,' but the truth is that a lot of people don't know,” he says. “Maybe we're not doing ourselves the best service by thinking we are the best providers of these services, because some physicians fail to see the need for continually educating patients about them. We need to educate our patients that we spend more time with skin than anybody, that we developed and perfected non-invasive treatments, and that we are the unqualified experts when it comes to these treatments,” says Dr. Gold.
what tips do you have for clinicians on navigating the balance of cosmeticmedical in their own practices?
One of the great assets of dermatology is the variety of services and procedures it encompasses, according to Dr. Gold. “Aside from treating rosacea or other medical conditions, dermatologists can assist patients with skin care and cover-up make-ups, become advocates for sun protection, and also educate them about the myriad of cosmetic services we provide.” Thus, the ubiquitous nature of the specialty presents unique challenges but also unique opportunities concerning how to navigate and incorporate these different elements.
While Dr. Gold feels it is important for all clinicians to remain open to the innumerable aspects of dermatology, he believes that every clinician will have his or her own approach toward achieving a balance in practice. “Whether you practice primarily medical, primarily cosmetic dermatology, or an even mix of both, always remember what brought us to this specialty. If you don't keep that going somehow, you lose what you're doing,” observes Dr. Gold. To illustrate the importance of a harmony of approaches in dermatology, Dr. Gold notes how the economic downturn in recent years has affected various specialties. “The numbers may shift depending on who you speak to, but the average general dermatologist's business may have dropped about five to 15 percent in the last five years, as compared to cosmetic dermatologists whose numbers have slipped about 15 to 25 percent, and plastic surgeons, whose revenues have taken a roughly 25 to 50 percent hit.” The reason why dermatologists have not taken the hit that others have is, in Dr. Gold's words: “People still have acne, eczema, psoriasis, poison ivy, cancers.” This points to the distinct position the specialty owns in medicine. And with advancements in medications and devices, dermatologists are increasingly in an optimum position to bridge the gaps. “While every dermatologist will navigate it differently, dermatology is a specialty that allows for a number of ways we can improve the lives of patients,” says Dr. Gold.
Dr. Gold has performed research for Syneron, Lumenis, and Solta Medical. Dr. Gold speaks on behalf of Syneron-Candela, Lumenis, Solta Medical, Alma Lasers, and Cynosure and owns stock in Lumenis.
Michael H. Gold, MD, FAAD is Founder and Medical Director of Gold Skin Care Center in Nashville, TN. He is President of DASIL: www.thedasil. org.