Figuring out Lasers
2. PULSED DYE LASER
(577-nanometer and 585-nanometer)
In the 1980s, the development of the pulsed dye laser (577- or 585-nanometers) offered the first real hope for selective removal of facial blood vessels without permanent side effects. Since their inception, pulsed dye lasers have been the ‘gold standard’ for the treatment of vascular lesions such as facial telangiectasia and portwine stains (red vascular birthmarks). (124, 138).
Effect of Pulsed Dye Laser on Rosacea
Throughout the late 1980’s and most of the 1990’s, the pulsed dye laser has been the most frequently used laser system for the treatment of rosacea. In the hands of an expert, the pulsed dye laser can reduce most of rosacea’s vascular symptoms:
• In the clinical study, “Flash Lamp Pumped Dye Laser for Rosacea-Associated Telangiectasia and Erythema”, Dr. Lowe and colleagues demonstrated that the pulsed dye laser was very effective at treating rosacea-related telangiectasia and facial redness (585-nanometer, Candela, SPTL1). (18) In this study, good to excellent results were obtained in 24 out of 27 rosacea patients (89%). These laser specialists also found that after elimination of the abnormal blood vessels, papule and pustule lesions decreased in 60% of the patients. After successful laser treatment, most rosacea patients were able to cut back or stop topical and systemic antibiotic therapy.
• In a recent review article, “Laser Therapy in the Management of Rosacea”, Drs. Laughlin and Dudley discuss the positive effect that laser therapy has on rosacea symptoms and facial flushing. (124) These laser experts have treated 700 rosacea patients throughout a 9-year period. They indicate that laser treatment provides an effective way to permanently decrease rosacea-related telangiectasia, facial redness, and facial flushing. Regarding facial flushing, they state, “Treatment in the early erythrematous stage has a pronounced effect on the patient’s ability to flush for a period of time. A decreased flushing response in areas treated with the pulsed dye laser is also observed in non-rosaceans that have been treated for telangiectasia or capillary malformations. It raises the question of whether early treatment of erythema and the decreased ability to flush could reduce the incidence and frequency of the secondary manifestations. Furthermore, patients with early rhinophyma will respond to treatment with the pulsed dye laser.”
• In a recent meeting at the American Academy of Dermatology, Dr. Clark presented clinical findings on the effect of pulsed dye laser therapy on rosacea. (137) He found that in 12 rosacea subjects, pulsed dye laser therapy resulted in significant clearance of facial telangiectasia, redness, and flushing after an average of 3 treatments. Patients were treated on only one side of the face, and the other side was left untreated as a control. Compared with the untreated side, patients experienced a 75% reduction in telangiectasia, a 50% reduction in redness, and a 55% reduction in flushing. There was also a trend towards a decrease in the number of papules and pustules after laser therapy.
• In a recent clinical study, the 585-nanometer pulsed dye laser was shown to be very effective in reducing the color and flushing of the rosacea “red nose”. (139) In this study, 24 out of 30 patients (80%) reported significant improvement after an average of 3 laser treatments.
• Medical laser specialists indicate that full-facial laser treatment is very effective at removing facial telangiectasia and decreasing facial redness in rosacea sufferers. (131)
• Dr. Bailin, former chairman at the Dept. of Dermatology, Cleveland Clinic Foundation, USA, indicates that laser therapy of the nose can significantly reduce rhinophyma. (132) He states, “Early treatment with a pulse dye laser can help shrink the nose, and often prevents further development of the condition.”
Limitations of Pulsed Dye Laser
Although the standard 577- and 585-nanometer pulsed dye lasers have a very good track record, and are still the most popular lasers, they do have two drawbacks that may limit their overall effectiveness in rosacea treatment. First, this older laser technology only uses one wavelength to treat blood vessels (i.e., either 577- or 585-nanometers). The wavelength setting on the laser is responsible for ‘tuning’ into blood vessels located at specific depths in the facial skin. So, if a laser only has one wavelength setting, it can only treat blood vessels located at one level in the facial skin. Standard pulsed dye lasers can only treat blood vessels very close to the surface of the skin. Second, this technology only employs a very short pulse, making it impossible to treat thick-walled blood vessels in the facial skin.
As flushing disorders always involve blood vessels of different sizes, thicknesses, and depths, traditional pulsed dye lasers are limited in their ability to treat rosacea and the underlying flushing disorder.
Below are several medical articles documenting these important limitations:
• In a recent medical study, “The Pulsed Dye Laser: Possibilities and Limits”, Dr. Hellwig and colleagues indicate that the main drawback to the 585-nanometer pulsed dye laser is its minimal penetration into the skin and its short pulse duration. (140) This means that it cannot treat deep blood vessels, or vessels that are thick-walled. (140)
• In a clinical study, “Epidermal Damage and Limited Coagulation Depth with the Flashlamp-Pumped Pulsed Dye Laser: A Histochemical Study”, Dr. Hohenleutner and colleagues found that the 585-nanometer pulsed dye laser did not effectively treat blood vessels that were in the deeper layers of the skin, or those with thick walls. (141) They conclude that the 585-nanometer pulsed dye laser is only minimally effective on facial vascular diseases that involve vessels of different sizes and depths. (141)
• Dr. Fiskerstrand and colleagues evaluated 51 patients treated with the pulsed dye laser for abnormally dilated blood vessels. (142) They found that only the most superficial vessels with the thinnest walls responded to treatment; deeper vessels that had thicker walls did not respond at all to pulsed dye laser treatment. (142)
• In agreement with the above findings, a medical article in Lasers in Surgery in Medicine (1999) by Dr. Barton and colleagues demonstrated that the pulsed dye laser was only effective at treating superficial, thin-walled blood vessels. (143) In this study, they found that deeper vessels were not treatable with standard pulse dye lasers. More specifically, they demonstrated that these lasers were only able to treat the top part of thick blood vessels (which did not remove the blood vessel from the vascular network). They also found that vessels over 60 microns did not respond well to treatment. This is an important finding, because 60 to 100 micron blood vessels are important feed vessels that supply large volumes of blood to the skin surface. If these vessels cannot be treated, then large volumes of blood can still be delivered to the skin.
Common Side Effects of Pulsed Dye Laser
Traditional pulsed dye lasers have a very good safety profile. The main side effects, although bothersome, are usually only temporary. The main side effects include:
• Purpura (blackish-blue discoloration): This bruising is an almost guaranteed side effect. It is wise to plan on 7 to 14 days of blackish-blue facial discoloration after treatment. (18, 137, 144, 145)
• Swelling: Significant facial swelling is noted by many patients. (146, 147)
• Crusting, scabbing, and blistering of treated area: Some patients also experience crusting, scabbing, and blistering of the treated areas. (18, 124, 141, 146)
• Facial redness: It is common for patients to experience increased redness in the treated areas. (146, 147) In most cases, this gradually disappears within a few weeks; however, in some cases, it may linger for more than a month.
• Facial pain: Facial pain is experienced by most patients undergoing pulsed dye laser treatment. In a study of 100 patients who underwent pulsed dye laser treatment on the face, 31 patients described the pain as mild, 24 described the pain as moderate, and 33 stated that the pain was severe. (146)
Recommendations for Rosacea Treatment
• Treat the entire flush zone: With most facial blood vessel disorders, physicians only treat isolated areas of redness. This is not the correct approach to rosacea treatment. It is highly recommended by rosacea specialists that physicians treat the entire flush zone of the rosacea sufferer’s face. Even if the patient just presents with redness on the tip of the nose or apple of the cheek, it is recommended that the laser physician treat the entire center of the face. It must be stressed that superficial red areas of facial skin are just the tip of the rosacea iceberg. There is usually extensive damage and dysfunction immediately around and below all areas of facial redness. Under some conditions, the physician may increase the effectiveness of treatment by inducing a full facial flush prior to laser therapy (to bring out those vessels that are on the verge of dysfunction or damage).
• Treat the rosacea sufferer several times: General pulsed dye laser physicians are often guilty of informing rosacea sufferers that they will only need one treatment (with the occasional light touch up). This is usually quite misleading and almost always results in under-treatment. In reality, these physicians are just talking about treating telangiectasia and some facial redness. But, in order to give rosacea sufferers more complete clearance of facial redness, flushing, swelling, and burning sensations (with longer-lasting results), rosacea specialists emphasize that it usually takes at least 3 full-faced treatments to give the patient the best chance for clearance. (18, 137, 139) More difficult cases may need up to five or six treatments.
There is considerable speculation by medical experts that repeated laser treatments may reduce the overall vascularity of the face by ‘turning off’ signals for blood vessel regrowth. It is speculated that growth factors from the skin and/or blood vessels (i.e., vascular endothelial growth factor, VEGF) may be produced in high concentrations during the first couple of laser treatments, and that with repeated treatments this signal decreases substantially resulting in reduced vessel regrowth and permanent replacement of blood vessels with healthy connective tissue.
• Do not treat rosacea sufferers with high levels of energy: General physicians that are very aggressive with their laser may cause lingering side effects to rosacea-sensitive skin and blood vessels. General laser physicians that take the ‘once and done’ treatment approach are often guilty of cranking up the energy to make sure that adequate heat is delivered to the blood vessels. However, with high energy and short pulses comes considerable risk that the blood vessels will explode and heat will affect surrounding tissue, nerves, and skin cells. (141) This can cause physical damage to skin cells and sensory nerves around the treated blood vessels, resulting in ultra-sensitive skin for long periods of time after laser surgery is completed. In a superb medical article, “Laser Therapy in the Management of Rosacea”, rosacea laser specialists stress that because rosacea skin is exquisitely sensitive, it is prudent to select the lower end of the power range for the treatment of these patients. (124)
My Personal Experience with Pulsed Dye Laser
I was treated with the 585-nanometer pulsed dye laser. In fact, I traveled out of state to see one of the best pulsed dye laser physicians on the East Coast. I was told by this physician that one treatment (and possibly a light touch up) would be enough for my case. With this mind set, the physician cranked the laser energy up to very high levels and blasted away. The results of my treatment were mixed. First of all, my side effects were substantial. I experienced significant swelling, to the point where my eyes were nearly swollen shut for 24 hours. I also experienced crusting and blistering of my facial skin for 10 days, and deep purpura for approximately 16 days. My face was extremely red and sensitive for the next 45 to 50 days. As my skin healed, I did notice that laser treatment resulted in significant clearance of my facial telangiectasia (approximately 70%), papules (approximately 65%), and chronic redness (approximately 50%). However, at the same time, I realized that several rosacea symptoms had worsened -- my face was now much more sensitive to environmental and topical skincare irritants, and my facial flushing and burning episodes had increased in frequency. This physician had been much too aggressive with his laser.
Even though I had a mixed response, I can still recommend pulsed dye laser treatment to rosacea sufferers (based on hundreds of positive reports from satisfied rosacea sufferers). However, it has become clear that rosacea patients need to be treated with extra care by their physicians; rosacea specialists highly recommed multiple treatments with low energy settings because this approach is associated with less side effects. I do not recommend the once and done (blasting away) approach to any rosacea sufferer.
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