2010 Q and A Interview with Dr Crouch

[Melissa W]

Dear Dr Crouch,

I developed very uncomfortable rosacea symptoms in April 2007 after having 'Microdermabrasion' to treat mild acne. The procedure was stopped early as my face went very red and sore. Ever since that day I flush very easily and have to moisturise thoroughly to help calm my skin down. I also have a lot of background redness mainly on the cheeks and nose, very tiny broken blood vessels and tiny rosacea spots develop after a bad flush leaving me with inflammation.

I have managed to keep the spots and some inflammation under control by taking a small dose of Isotretinoin weekly but I still have this reactive background redness which soon enough turns into a flush and lasts a long time!

I am being treated by Dr Neil Walker with pulsed dye laser to help get rid of the background redness and reduce flushing. I am having my fourth and final non bruising treatment this Friday however I have only noticed a mild improvement, I don't think it penetrates deep enough and four treatments cost over £2,000!

Is there any other laser I can try which will have more noticeable effects? My skin is very transparent so I don't know why the improvements aren't more drastic?
I used to have very white pale skin and I would really like it back.

Thanks for you time,

Katie

Dear Katie,
Thank you for your question. Pulsed Dye Laser is usually quite effective and Dr Neil Walker is a highly respected laser physician – I think you are in excellent hands. Sometimes IPL can work very well following PDL even though it might not be effective until after the PDL has done its initial work. Nd:YAG might also assist with the flushing. I would recommend a test patch with both to help decide.

[Melissa W]

Hi Dr. Crouch,
Thank you so much for your help! I had my first IPL treatment for my rosacea. My cheeks and forehead were VERY red after teh treatment, adn now, 2 weeks later, I have some red scaley spots on my cheeks and forehead still. Any idea what might have caused this? Do you think they will go away? My rosacea seems to be more prevalent now than before my IPL treatments. I definitely have rosacea, and the machine was a luimens. Thanks!

Dear Aislinn,
Thank you for your question. Tricky to know without seeing you – have you asked the practitioner who delivered the treatments? In my experience, I wound not expect redness after treatment to last more than a few hours – certainly not more than the rest of the day. Crusting of the skin or scaly marks might indicate that the epidermis hasn’t tolerated the fluence so well so it would be good to let your treating practitioner know so that they can evaluate your skin carefully. If you live a long way away from your practitioner, keep a brief diary and take some high resolution pictures and take them along to show your practitioner next time you have an appointment. I know that many patients seek rapid resolution of symptoms (who wouldn’t) however at The Burghley Park Clinic we have found, based on many years of experience and careful observation that the approach that seems to be the most successful seems to be gentle sustained improvement based on moderated treatment rather than perhaps more aggressive treatments which can provide great initial results but the patients often report quick fix then rapid return.
I hope that this advice helps,
Kind regards,
Peter
Disclaimer
Any advice or information provided here does not and is not intended to be and should not be taken to constitute specific medical advice given to any group or individual. This general advice is provided with the guidance that any person who believes that they may be suffering from any medical condition should seek professional advice from a qualified, registered/licensed physician who has the opportunity to meet with the patient, take a medical history, examine the patient and provide specific advice and or treatment based on their experience diagnosing and treating that condition or range of conditions. No general advice provided here should be taken to replace or in any way contradict advice provided by a physician able to meet with the patient, take a medical history, examine the patient and provide specific advice and or treatment based on their experience diagnosing and treating that condition or range of conditions.

[Melissa W]

Hi Dr. Crouch:

I am having IPL treatments done. The 1st one the doctor used eye protectors but on the 2nd one he said it was not necessary that all i had to do was close my eyes. This way he could get close to the area under my eyes. Do you think the patient should always use eye protectors ? I have dry eyes so I thought maybe this way the dr. gets close under my eyes to help with the dryness.

Thank you Dr. Crouch.

Alba

Dear Alba,
Thank you for your question. We always use eye protection however, whilst it has risks, generally IPL isn’t truly as risky as laser in terms of eye damage and your practitioner isn’t necessarily acting recklessly with regard to your eyesight. In order to get close to the eyes, some clinics use sticky eye protector pads. I personally don’t like them (when I have my treatments) because I don’t particularly like my eyelids stuck down. If I needed to get closer to the eyes (somewhere I tend not to prefer to go too close to anyway) then the eye shields would be an alternative. I think that it is important for treating practitioners to appreciate how isolating it can feel to have your vision even temporarily suspended – particularly though a treatment which, whilst not too painful, is normally quite startling. I think that talking to the patient during treatment always explaining not only what you are about to do but when you are about to do it. I always count down to a treatment pulse as in here we go 3, 2, 1 … <Flash> etc and empathise with the patient – I know what they are going through and I don’t much like it either. If I had a patient with no eye protection on (something I would not do) then, other than asking them not to, I’m not sure that I could guarantee that they wouldn’t open their eyes at the point that the IPL flashed and that would worry me. Certainly the IPL discharge and very short distance directly into an eye has significant potential to damage eyesight and the skin of the eyelids is quite unlike the skin on the face – much more fragile and delicate.
I hope that this advice helps,
Kind regards,
Peter
Disclaimer
Any advice or information provided here does not and is not intended to be and should not be taken to constitute specific medical advice given to any group or individual. This general advice is provided with the guidance that any person who believes that they may be suffering from any medical condition should seek professional advice from a qualified, registered/licensed physician who has the opportunity to meet with the patient, take a medical history, examine the patient and provide specific advice and or treatment based on their experience diagnosing and treating that condition or range of conditions. No general advice provided here should be taken to replace or in any way contradict advice provided by a physician able to meet with the patient, take a medical history, examine the patient and provide specific advice and or treatment based on their experience diagnosing and treating that condition or range of conditions.

[Melissa W]

Hi Dr Crouch, Do you think that the IPL brand really cares? I mean machines with same power but different brand. if you think so, what brands are the best? I ask taht because I'm thinking take IPL sessions from a IPL machines that is not a Lumenis or Vasculight.

Thank you in advance.

Dear Yellowred,
Thank you for your question. I have experience with IPL manufactured by Lumenis – namely the Vasculight, the Quantum and the Lumenis One. I have observed treatments with other machines. I would say that I think that in theory, it should not matter if the treatment output of each machine was identical and the pre- , during- and post-treatment cooling was the same. However, different brands seem to deliver quite different outputs and use a variety of different methods to cool. The treatment parameters are different brand to brand and between machines within the same brand and the method of creating the energy and delivering the cooling can differ in subtle (yet important) ways. How old a machine is and how recently was it serviced are also considerations. Brand new machines can deliver higher fluences (every component is brand new) until they “settle down” and that is something that any experienced practitioner with a new or recently serviced machine will bear in mind.
We researched long and hard before selecting Lumenis as our chosen brand for IPL. We were keen to choose the best and it was certainly not the cheapest but we hoped, putting quality high on our agenda, our Lumenis One has provided us with great value and has served us very well thus far. We do have more than one brand of laser at our clinic but Lumenis is our choice for IPL.
All the above being said, that is not to say that there arent other perfectly acceptable alternative brands out there on the market and in use. I can only speak from personal experience and I know which brand of IPL I would wish to be treated with myself or recommend to a close friend or family member.
I hope that this advice helps,
Kind regards,
Peter
Disclaimer
Any advice or information provided here does not and is not intended to be and should not be taken to constitute specific medical advice given to any group or individual. This general advice is provided with the guidance that any person who believes that they may be suffering from any medical condition should seek professional advice from a qualified, registered/licensed physician who has the opportunity to meet with the patient, take a medical history, examine the patient and provide specific advice and or treatment based on their experience diagnosing and treating that condition or range of conditions. No general advice provided here should be taken to replace or in any way contradict advice provided by a physician able to meet with the patient, take a medical history, examine the patient and provide specific advice and or treatment based on their experience diagnosing and treating that condition or range of conditions.

[Melissa W]

Dr. Crouch,

Thanks for taking the time to answer our questions. I have noticed in your prior interviews that you are not a huge fan of Veinwave. Two quick questions. First: My prominent nose veins are a far bigger aggravation to me than my mild rosacea. I believe you like the Gemini over veinwave even in a case like mine, but would you say Veinwave is at least worth a try in such cases? Second: Would you venture a general percentage or any hint of the likelihood of Veinwave treatments making the veins worse than they already are, from your experience? An ineffective treatment won't hurt me too much. But I'd like to get a feel for the chances of making my nose even worse. Thank you!

James

Dear James,
Thank you for your question. I think that there is quite a lot of, well, “marketing hype” about Veinwave. We have a veinwave machine and I was trained by the Veinwave’s inventor. It certainly has a place but no treatment provides complete painless effective treatments with absence of side effects and no downtime. I am supportive of trying Veinwave as an alternative but in a clinic with many alternatives, Veinwave has its place but not one which I would promote as vigorously as those who may have a commercial agenda. I trust that treatments would always be recommended on the basis that they were the best choice or alternative for any patient and in a clinic with many lasers and IPL plus radiofrequency and Veinwave, one which charges by practitioner time rather than itemised by treatment, we are free to choose which of many treatments and machines are the best choice. At our Clinic we charge for the clinician expertise but assure a wide choice of treatment strategies for that practitioner and patient to choose from. In the past 3 years, I have recommended trying a Veinwave test patch to just two patients and they both had a test patch and chose an alternative treatment when they compared the results.
Veinwave, correctly delivered is highly unlikely to make the veins any worse – so in summary, Veinwave is certainly worth a try, but I would not get sucked n by the marketing hype and go for a test patch first.
I hope that this advice helps,
Kind regards,
Peter
Disclaimer
Any advice or information provided here does not and is not intended to be and should not be taken to constitute specific medical advice given to any group or individual. This general advice is provided with the guidance that any person who believes that they may be suffering from any medical condition should seek professional advice from a qualified, registered/licensed physician who has the opportunity to meet with the patient, take a medical history, examine the patient and provide specific advice and or treatment based on their experience diagnosing and treating that condition or range of conditions. No general advice provided here should be taken to replace or in any way contradict advice provided by a physician able to meet with the patient, take a medical history, examine the patient and provide specific advice and or treatment based on their experience diagnosing and treating that condition or range of conditions.

[Melissa W]

Hi Dr Crouch,
Thank you for allowing us this opportunity once again.

My question is rather frivolous I am afraid. I have a couple of small hyperpigmented spots on my cheeks that have appeared in the last year and a half and surprisingly they really bother me. Compared to the burning of rosacea though they are nothing but nonetheless if I could make them disappear that would be lovely. My derm says they are freckles that occur with exposure to the sun even though I always wear sunblock (and reapply as necessary) while outside. I am very fair in coloring and while outside for any length of time apply a sunblock of zinc oxide and titanium dioxide of 60 spf.

Is there any laser/IPL procedure or any other treatment that you know of that could get rid of these hyperpigmented spots without aggravating my rosacea? My skin is ultrasensitive so I think topicals like hydroquinone, azelaic acid, niacinamide, and retinoids are out but am wondering if there is any treatment you would recommend even if it is one of these topicals since I have not yet tried anything to take care of this issue.

Thank you again and I hope all is well with you and your family.

Best wishes,
Melissa

Dear Melissa,Thank you for your questions and thank you for setting up and moderating the Q&A (and thank you for your best wishes).
Solar freckles (often called solar lentigo – plural is solar lentigines) can be treated very nicely with IPL. It is usually worth checking that any pigmented marks are benign (most are but you don’t want to miss an early melanoma) but you have already asked your dermatologist to confirm the diagnosis – so that is good. The laser which is sometimes used for these is the KTP 532nm laser but in my experience, IPL would be my first choice because KTP can cause more post-treatment swelling (and occasionally slight crusting) and IPL can deliver great results without these side effects or much downtime. Strict sun avoidance is probably the only way to lessen the chances of more but it will be historical sun exposure that will lead to their development as we mature so the approach I would probably advise would be to have an IPL every few years or so to keep it under control.
I hope that this advice helps,
Kind regards,
Peter
Disclaimer
Any advice or information provided here does not and is not intended to be and should not be taken to constitute specific medical advice given to any group or individual. This general advice is provided with the guidance that any person who believes that they may be suffering from any medical condition should seek professional advice from a qualified, registered/licensed physician who has the opportunity to meet with the patient, take a medical history, examine the patient and provide specific advice and or treatment based on their experience diagnosing and treating that condition or range of conditions. No general advice provided here should be taken to replace or in any way contradict advice provided by a physician able to meet with the patient, take a medical history, examine the patient and provide specific advice and or treatment based on their experience diagnosing and treating that condition or range of conditions.

[Melissa W]

Hi Dr Crouch,

Thank you so much for once again agreeing to answer our questions.
In your opinion is it possible for IPL treatment, that has always been well tolerated in the past, to suddenly cause adverse effects?
I've had 15 or so IPL treatments over the past 7 years and have always had great success. Unfortunately I recently had two treatments (same Doctor, same settings) and they have caused extreme dryness all over my face and a huge flare of pustules and oily skin on my nose. I am pretty certain that it was the IPL that caused this because it happened after both treatments, but once again I should stress that IPL has never caused me any problems in the past.

My second question links to the first and concerns the relationship between Seb Derm, IPL and the N-Lite laser. I understand that IPL can flare Seb Derm (maybe this is what has happened to me) and I was just wondering if we had any idea why exactly IPL causes Seb Derm symptoms to worsen? I understand that you advocate the use of N-Lite to try and counter these effects, and was once again wondering if you know why N-Lite specifically helps in the treatment of Seb Derm.

Obviously I understand that it is difficult for you to recommend a particular treatment without viewing my skin personally (I believe I am currently on your waiting list for a consultation anyway), but do you think N-Lite would be beneficial for somebody that has very large pores, pustules, and severe oiliness (all on the nose)? I'm hoping that I can eventually turn to N-Lite to help undo some of the damage recently caused by IPL.

Once again thank you for all that you do to try and help fellow sufferers of Rosacea.

Kind regards,

James

Dear James,
Thank you for your question. I wonder if you have had a flare up of Seb Derm which can happen following IPL. I think that what can often confuse is that rosacea can progress despite treatment and seb derm may emerge and then be aggravated by IPL. I’m not sure that we completely understand why IPL worsens seb derm but hat we have fond is that nLite on it own can help acne and seb derm.
Where the “NLite chaser” treatment comes into play, following IPL is that it seems to protect susceptible patients from a seb derm flare provided that the IPL is within 6 months of the NLite treatment. Therefore, an NLite chaser protects the patient for the next IPL treatment not the current one.
IPL would help with the pores and the oiliness – Nlite is unlikely to help with that but combined with a gentle IPL – I would be hopeful that we could make progress on both fronts.
I hope that this advice helps,
Kind regards,
Peter
Disclaimer
Any advice or information provided here does not and is not intended to be and should not be taken to constitute specific medical advice given to any group or individual. This general advice is provided with the guidance that any person who believes that they may be suffering from any medical condition should seek professional advice from a qualified, registered/licensed physician who has the opportunity to meet with the patient, take a medical history, examine the patient and provide specific advice and or treatment based on their experience diagnosing and treating that condition or range of conditions. No general advice provided here should be taken to replace or in any way contradict advice provided by a physician able to meet with the patient, take a medical history, examine the patient and provide specific advice and or treatment based on their experience diagnosing and treating that condition or range of conditions.

[Melissa W]

Hello Dr Crouch,

Over time, I have read a fair bit about IPL (and also spoken to some practitioners too), with the thought that it might be an effective treatment for my rosacea. However, it sometimes seems that, as time goes on, more problems seem to be reported as being associated with IPL treatment. Do you think this is a reasonable assessment – would you say there are increasing reservations held amongst practitioners about IPL? And if so, is there a feeling that enthusiasm for IPL as a ‘relatively new’ (?) treatment has meant that it has perhaps not been used selectively enough?

Also, I understand that there are limits as to how close you can get to the eyes when carrying out any kind of laser/light treatment. Can you give any idea, for someone who has thread veins which veer up towards, nearby and over the eye socket, how far is ‘far enough’ away?

I seem to have largely ‘managed’ the rosacea so far, with the spots, veins and blotches wreaking havoc on my face occasionally, rather than most or all of the time; however, I feel that recently the symptoms have started to ‘accelerate’ and so I want to try and head things off at the pass before things worsen considerably. Are you able to say how long, approximately, is the waiting list for an appointment at your clinic; and do you have any update on the new methods getting in contact with you (recently announced elsewhere on these boards)? Apologies if this isn't the right place for this question, but I’m having difficulty getting in touch thus far.

Many thanks in advance, and best regards.

Dear WhoRay,
Thank you for your question. I think that IPL has been around for quite a while and the problems seem to me to be more likely to be associated with the machine used or the protocol used than with the technology. I have my rosacea treated with IPL and I would recommend it to a close friend or relative if they were suitable. Not sure how fairer I could put it than that.
The limit I choose for the eyes is not to go anywhere past the orbital rim – i.e. the bony margin of the eye socket. Beyond this area, I feel the risk is rising. Clearly other practitioners are able to go closer to the eyes but not for me (it is possible that I am being too cautious but I always use the yardstick – if I wouldn’t recommend it to a close friend or relative then I wouldn’t advise a patient to have it done).
I realise the frustration felt by those trying to get appointments and we have listened to and considered the feedback. We have been somewhat overwhelmed by the interest shown in appointments however we have not been complacent. We have taken a few months to expand the appointment capacity and we have taken a short pause to regroup and the result is that we have made some dramatic changes to the appointment system to bring it fully on-line so that existing and prospective patients once registered can view, reserve and book appointments 24 hours a day, 365 days a year. The system went live last Friday and many patients have booked successfully this week and the feedback has been good so far. On-line registration for new patients seeking initial assessments and patch testing has just opened (this was delayed until later this week as we had to install spam protection to avoid fake registrations by web robots) and this can be accessed via the clinic website on www.burghleyparkclinic.com or directly using the shortcut www.newpatientregistration.co.uk . Once registered, patients are sent login credentials and they can choose from a range of appointments including top-up treatments with my colleague Christine (same settings as before). There are over 100 treatment and assessment slots over the next 4 months and every 4th appointment is set aside and reserved for brand new patients. We hope that the introduction of this on-line system will herald a whole new way of efficiency in terms of booking and this will enable patients to book new and follow up appointments at any time and release Christine (who is a highly experienced practitioner) from booking appointments so that she can offer top-up treatments (including mine). It is early days and we welcome positive and negative feedback – we have written most of the online booking software in house so that it links directly to our clinical appointment system and I am very proud of our team for having done this for the Clinic. It seems to me that on-line booking is fast becoming the way we operate in a modern world and it is good to be able to extend this functionality to those who wish to book. Do let us know what you think if you try it – we trust that you will be pleasantly surprised.
I hope that this advice helps,
Kind regards,
Peter
Disclaimer
Any advice or information provided here does not and is not intended to be and should not be taken to constitute specific medical advice given to any group or individual. This general advice is provided with the guidance that any person who believes that they may be suffering from any medical condition should seek professional advice from a qualified, registered/licensed physician who has the opportunity to meet with the patient, take a medical history, examine the patient and provide specific advice and or treatment based on their experience diagnosing and treating that condition or range of conditions. No general advice provided here should be taken to replace or in any way contradict advice provided by a physician able to meet with the patient, take a medical history, examine the patient and provide specific advice and or treatment based on their experience diagnosing and treating that condition or range of conditions.

[Melissa W]

Dr. Crouch,

if you're dealing with severe vascular rosacea accompanied by debilitating flushing, do you prefer to treat it with IPL or V Beam? Which have you gotten better results with?

I've had both, and am seeing that V Beam seems to rupture more blood vessels while putting less heat into the skin and causing less post treatment flushing.

Would love to get your opinion on this. Thank you for taking the time to answer our questions.

Dear WrinkledClue,
Thank you for your question. I tend to use IPL and Nd:YAG as alternating treatments – one to make progress with the redness- the other to hopefully improve the flushing. Pulsed Dye laser can help with shutting down the vessels (like IPL does) and this may help with the flushing (fewer vessels less places for the blood to flow into) however, in my experience Nd:YAG is the way to go with the flushing.
I hope that this advice helps,
Kind regards,
Peter
Disclaimer
Any advice or information provided here does not and is not intended to be and should not be taken to constitute specific medical advice given to any group or individual. This general advice is provided with the guidance that any person who believes that they may be suffering from any medical condition should seek professional advice from a qualified, registered/licensed physician who has the opportunity to meet with the patient, take a medical history, examine the patient and provide specific advice and or treatment based on their experience diagnosing and treating that condition or range of conditions. No general advice provided here should be taken to replace or in any way contradict advice provided by a physician able to meet with the patient, take a medical history, examine the patient and provide specific advice and or treatment based on their experience diagnosing and treating that condition or range of conditions.

[Melissa W]

Dear Dr. Crouch,

1. I have a friend who has mild rosacea, one or 2 bumps appear on and off. She had Vbeam about 3 years ago and it helped to keep the redness/flushing away. Her cheecks have started to flush and get red more often again. She is wondering which is better for this Vbeam or IPL? The Vbeam helped her 3 years ago, she had 3 Vbeam treatments. Also, she is Latin, tan color skin.

2. I flush badly on my ears even when my face is not flushing. I've had 3 IPL treatments and they seem to be helping my face but my derm says he can not treat the ears. Do you have any recommendations for the ears?

Thank you so much for your help and taking time to answer our questions.

Gratefully,

Alba

Dear Alba,
Thank you for your question. If your friend has tanned skin then I would be careful with IPL as this could risk her pigment (and her natural pigment is too precious to risk). If flushing is her problem then I would suggest looking at NdYAG as this is highly unlikely to risk her natural pigment. As the VBeam helped her before, (presumably with no problems) then I would suggest starting with the V Beam again.
I too steer well away from the ears – I know that some patients tell me that they have had their ears treated successfully and agian, perhaps I am being too cautious, but I think that IPL on the ears could be risky.
Colin Dahl has written a very sensible paper on the Warm Room Flush Response. if you Google it using the following search term - A Practical Understanding of Rosacea, Part 1: Heat Regulation and the Warm Room Flush Phenomenon, By Colin Dahl, Chief Scientist, Australian Sciences, it should come up.
I hope that this advice helps,
Kind regards,
Peter
Disclaimer
Any advice or information provided here does not and is not intended to be and should not be taken to constitute specific medical advice given to any group or individual. This general advice is provided with the guidance that any person who believes that they may be suffering from any medical condition should seek professional advice from a qualified, registered/licensed physician who has the opportunity to meet with the patient, take a medical history, examine the patient and provide specific advice and or treatment based on their experience diagnosing and treating that condition or range of conditions. No general advice provided here should be taken to replace or in any way contradict advice provided by a physician able to meet with the patient, take a medical history, examine the patient and provide specific advice and or treatment based on their experience diagnosing and treating that condition or range of conditions.