Latest Advances in Rosacea Treatment

Triple-Pass Laser Treatment
By: John Jesitus and Dr. Geoffrey Nase

Indianapolis — A detailed three-step laser process provides a far more effective treatment for rosacea than current therapies, according to Geoffrey Nase, Ph.D., a leading rosacea researcher who has battled the disorder himself.

Dr. Nase says the standard treatment regimen for rosacea only focuses on the superficial symptoms such as papules and pustules and does not address the underlying neurovascular disorder. Though not a dermatologist, Dr. Nase bases these assertions on his medical physiology training, his numerous publications on rosacea, his clinical work with dermatologists and collaboration with leading laser specialists like Dr. Jerry Darm. Dr. Nase is a rosacea research specialist for the Indiana American Medical Association Affiliate and rosacea treatment analyst, Indiana University School of Medicine, Indianapolis .

"Physicians often use harmful topical medications, steroids or irritating exfoliating treatments," Dr. Nase tells Dermatology Times . "But these treatments are counterproductive; they anger the underlying rosacea beast by sensitizing facial blood vessels and nerves." He says doctors can be too focused on the superficial papules and pustules and are often confused when patients come back with clear faces, but are complaining that their faces are fire-red, flushed or burning from rosacea triggers. "It is never a good tradeoff to clear the papules at the expense of pushing the underlying disorder into the more serious stages," he says.

Personal experience

Physicians put Dr. Nase on various oral and topical antibiotics during a five-year period when he was in his mid-20s. He says dermatologists also prescribed topical medications clearly contraindicated for rosacea, triggering "angry face syndrome." His rosacea continued to worsen, but he was told there was nothing else doctors could do for him. He was told he would have to live with his red, burning face, and his rhinophyma that was certain to progress over time until he became a candidate for surgery.

As do many rosacea patients, Dr. Nase experienced frequent flare-ups triggered by a wide variety of causes, from skincare products to temperature changes, mental concentration, and any form of stress and light exercise. The typical patient can have hundreds of triggers, which can include steam radiating from hot foods and warmth created by the face against a pillow or exertion associated with doing simple household chores. Avoiding such triggers proves almost impossible. Many patients wind up having to choose between their jobs, for example, and their health.

After extensive research into lasers, multiple medical publications and in-depth discussions with leaders in the field, Dr. Darm and Dr. Nase developed a treatment regimen that focuses on the underlying disorder — vascular dysfunction, vascular damage and angiogenesis. He urges interested physicians to learn more about this cutting-edge treatment regimen (available at ).

Cutting-Edge Treatment Protocols for Rosacea Symptoms : Collaboration with Dr. Darm

Dr. Nase describes a brief overview of this treatment as follows:

"Dr. Darm performs a triple pass and sometimes a quadruple pass with two lasers and Intense Pulsed Light while inducing severe facial flushing in patients with multiple prescription topical dilators, oral dilators and thermoregulatory heating units.. He notes that they often heat patients with thermoregulatory heating units to induce a thermoregulatory flush to bring out vessels that normal lasers never treat. Inducing a strong, deep flush in rosacea patients is of the utmost importance because many of the vessels adjacent to the treatment area constrict during laser treatment due to a propagated constrictor response induced by thrombosis at the treatment spot."

To treat microvessels located directly beneath the epidermis, Dr. Darm uses two passes with the Photoderm VL-Flashlamp (Lumenis Aesthetics) set at short- and medium-wavelengths in order to remove several superficial vessel types intimately involved in rosacea.

Dr. Nase says this is where dermatologists usually stop treatment, missing the damaged and dysfunctional vessels just below the microvessels, which are central to vascular pathogenesis

To treat these vessels, Dr. Darm uses a 1064 nm Nd:YAG laser, with low energies, short pulse durations and multiple passes, continually checking to see that the patient still has an active deep flush and constantly stopping to determine the level of vascular photocoagulation with portable magnification systems. The final laser step involves a single pass with an N-Light 350 ms pulsed dye laser (ICN Pharmaceuticals) to treat papules, pustules and the lumpy-bumpy facial texture.

This multi-pass treatment protocol with several different laser and IPL devices has changed the face of laser treatment as we know it. This protocol is able to treat the facial redness, flushing intensity & duration, swelling and neuropathic pain that no other single pass traditional treatment or pharmacological agent has ever been able to successfully treat..

In collaboration with Dr. Nase, Dr. Darm follows up for two weeks after treatment with macrolide antibiotics to decrease regrowth of blood vessels into the laser-treated areas.

Neuropathic rosacea

He says neurovascular dysfunction is the root of the disorder and that it does not make sense to focus on the papules as though they were acne lesions. Additionally, he says a new clinical subtype of rosacea has recently been identified. Though not officially recognized yet, neuropathic rosacea (Subtype 5) is believed to be the most debilitating form of the disease.

Hallmarks of neuropathic rosacea include bouts of centrofacial burning and pain sensations following exposure to triggers. Such bouts usually last more than 30 minutes. More serious cases can become semi-permanent if dermal inflammation or various inflammatory cytokines damage or permanently activate sensory nociceptors. In severe cases, inflammation may trigger these sensory nociceptors in the absence of external triggers (Izumi H. Pharmacol Ther. 1999;81:141-161).

Future treatments

In the future, hope for rosacea sufferers may ultimately lie in attacking the disease at the genetic level, as many pharmaceutical companies are now doing for atopic dermatitis (AD) and other inflammatory skin disorders.

Unfortunately, although Dr. Nase has contacted 17 pharmaceutical companies in the months since co-founding the Rosacea Research Foundation (see editorial), he says he has found companies unwilling to explore such options.

"Some companies are working with VEGF antagonists, angiogenesis inhibitors, vascular smooth muscle modulators, nerve hyperpolarizers, signal transduction kinase inhibitors and drugs that could really get to the heart of rosacea," he says. "But I was told, 'we have no interest in rosacea. There's no money to be made. It's already been cured.' Sadly, this is a common misconception. For the last 10 years, there have been no real advances in rosacea treatment. It certainly has not been cured and is far from being treated effectively." This laser protocol is the first real new effective advancement in the treatment of rosacea symptoms and triggers.

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