The redness and flushing, which are the most prominent and common features of rosacea, are best treated with lasers. In fact, laser treatment is the only therapy that treats the root of the problem and not just the symptoms. Linear blood vessels, those little spider veins on the face, can be very effectively treated with a long pulse-duration, pulsed-dye laser (PDL) or 532nm KTP Nd:YAG laser. Generalized, diffuse redness can also be removed with laser treatment. Several laser sessions (generally 2-4) are needed for intial treatment, although most patients see a significant improvement following a single session. Laser treatment results in removal of most spider veins, and a dramatic reduction is facial redness. After a series of treatments, the number and severity of rosacea flares, as well as the generalized baseline redness, should be dramatically reduced. Studies also have demonstrated that laser treatments can improve the pimples associated with rosacea. Sun-protection including UV-blocking window film and DAILY sunscreen are essential at preventing more veins from coming. With optimal sun-protection, re-treatment may not be necessary for months or years, and often requires only 1-2 treatments.
Poikiloderma of Civatte or POC is an extremely common condition with a long uncommon name. POC is simply neck redness caused by the sun. Like rosacea, POC most commonly occurs in light-skinned people, in sun-exposed areas of the neck. Neck skin is unusually sensitive to the sun, and develops a network of blood vessels that often leak blood into the skin resulting in redness as well as brown pigmentation due to old red blood cells that have leaked into the skin, as well as the inflammation that this ‘hemosiderin’, or dead red blood cells, causes. The treatment is to lighten the pigmentation often with topical treatments like alpha-hydroxy acids (glycolic acid is one example), followed by treatment with the pulsed-dye laser (PDL). The PDL targets the redness quite well, and after treatment there may be some purpura, or bruising. The neck is often more sensitive to topical lotions and laser treatments than the face is, so different settings may be required on the neck versus the face.
A nevus araneus is a small, usually pencil-eraser-sized, spot that has a central capillary surrounded by smaller capillaries radiating outward, giving the appearance of a small red spider (sort of). These small spots most often occur on the face, but also can occur on the chest, abdomen or extremities. They are common in children, adults with rosacea, and often occur in women during pregnancy, and can result from hormone fluctuations and other causes. Most commonly, they show up for no reason at all. They respond extremely well to the pulsed-dye laser, and after treatment there is usually a bruise at the treatment site for about a week or more. Nevus araneuses that have been present for over a year will often require more than one treatment, while those present less than a year more often require 1-2 treatments.
Lasers emit very specific colors, or wavelengths of light. When treating the unwanted blood vessels and generalized redness of rosacea, Pulsed-dye lasers (PDLs) and KTP lasers are optimal. These lasers emit yellow-orange light (PDLs) or green light (KTP lasers), and these colors, or wavelengths of light, are selectively absorbed by the unwanted blood vessels in skin affected by rosacea. This results in heating of the blood vessels, with much less heating of surrounding skin. The melanin pigment in the top layer of skin (the epidermis) also absorbs many colors of light, and thus can be an unintended target of laser treatment to remove unwanted blood vessels.
To minimize damage to the surface of the skin, cooling devices such as contact cooling plates or sprays that cool the skin by evaporation are used together with the PDLs and KTP lasers. The lasers damage the unwanted blood vessels that have been acquired by long-term sun-exposure in rosacea patients, because the orange and green light are selectively taken up by hemoglobin in the blood vessels of the skin.
These lasers are ‘pulsed’ in a flash of light-long enough to heat the unwanted blood vessels, but short enough to prevent the heat from spreading to surrounding skin causing a scar. An analogous situation is when one touches a stove that is on, a quick touch does not results in a burn, but leave your finder there too long, and the heat spreads to the underlying skin with regrettable results. Cooling sprays that evaporate very rapidly, cooling plates with cold liquid recirculating within them, and forced cold air are all used to cool the surface of the skin, further protecting it from damage. The surface of the skin overlying unwanted blood vessels has melanin pigment that is designed to absorb light. This means that lasers can hurt the surface of the skin, especially more darkly pigmented skin. Cooling devices can protect the surface while allowing the laser to heat the unwanted blood vessels below.
But how do lasers ‘know’ to hurt the new, unwanted blood vessels acquired from the sun, but not ‘normal’ veins supplying the skin? Luckily, the pulses used to remove unwanted blood vessels are too long to ‘see’ the normal vessels that supply the skin, thus leaving the skin unharmed. Pretty cool!
Lasers are complex devices that take light from a flashlamp (strobe-light) or diode laser source, and through a complex process turn it into laser light of a single wavelength. In the case of lasers used to remove unwanted blood vessels and redness, these are pulsed-dye lasers (PDLs) emitting yellow-orange 595 nm light, or KTP lasers emitting green 532 nm light. Since hemoglobin within blood vessels absorb this light preferentially as compared to surrounding skin, lasers can remove blood vessels without hurting the skin. Intense pulsed light sources (IPLs) also start with a flashlamp, but instead of using a complex laser cavity to produce a single wavelength of light, these devices simply place a filter in front of the flashlamp, blocking some, but not most of the unwanted wavelengths that deliver heat into the skin, but without removing unwanted blood vessels. IPLs can remove unwanted blood vessels, but they do so less efficiently and with a significantly greater risk of side effects than the PDLs or KTP lasers.
The two lasers that are most effective at treating rosacea and spider veins are the 595 nm, pulsed-dye laser, and the 532 nm KTP laser, because these wavelengths, or colors, of light are strongly absorbed by hemoglobin in blood vessels of the skin. The light energy is absorbed more strongly by blood vessels than by the surrounding skin structures, and damages the unwanted blood vessels, while sparing the surrounding skin. The only other part of skin that strongly absorbs light is the melanin pigment in the epidermis. The epidermis is cooled by various cooling devices added to these lasers to protect it. Cooling devices use a spray that evaporates rapidly to cool the skin, forced cold air, or a chilled sapphire plate through which the laser fires.
The pulsed-dye laser (PDL) is the first of the ‘modern era’ pulsed lasers to be applied in widespread use for treating skin. This laser emits yellow to orange light and was first used to treat port-wine stain birthmarks. The current, more modern PDL emits orange, 595 nm light with an adjustable pulse-duration for treating many sizes of facial blood vessels. The most commonly used PDL (Candela V-Beam Perfecta®) incorporates a cooling device that cools the surface of the skin with a cooling spray that evaporates just prior to the laser firing, so as not to injure it. Melanin pigment in skin absorbs many wavelengths of light, including laser light, and without cooling the laser could irritate the skin’s superficial layers. Generally, longer pulse-durations are used to treat larger linear spider veins, while shorter ones are used to treat generalized, or diffuse, redness. The main side effects of PDL treatment are some swelling after treatment, and bruising or purpura. Purpura is quite noticeable when it occurs, but does not hurt. Modern PDLs are much less likely to cause purpura after treatment than older devices, and it always resolves, typically within a week after treatment.
The 532 nm KTP laser uses a KTP crystal to shorten the 1,064 nm wavelength of a Nd:YAG laser, and produces green light that targets the hemoglobin in unwanted blood vessels in the skin. The main KTP laser in use today (Cutera Excel-V®) targets hemoglobin and heats vessels causing their destruction. This laser uses a chilled sapphire plate to cool the surface of the skin, an unintended target of laser treatment. Modern KTP lasers deliver large beam diameters and offer a wide range of pulse-durations to target large linear vessels and diffuse redness.
Other devices which are used to treat the spider veins and diffuse redness of rosacea, but are sub-optimal compared to the PDL and KTP are the Intense pulsed-light (IPL) and the 1,064 nm Nd:YAG laser. The IPL is not a laser, and uses a filter placed in front of a very strong strobe light or flashlamp. The problem with this system for treating blood vessels is that hemoglobin has quite narrow bands of laser absorption, and much of the light emitted by an IPL isn’t strongly absorbed by hemoglobin. Thus, this light can contribute to side-effects by heating the skin, but not removing target blood vessels. The IPL is a jack-of-all-trades but master of none. The 1,064 nm laser is one wavelength of laser energy, but this energy is not strongly absorbed by hemoglobin. Thus large energies are required to remove small red blood vessels, and the range between successful treatment and injuring the skin, the ‘therapeutic window’, is quite small.
Most people find the treatment tolerably annoying or slightly uncomfortable. Because everyone has a different threshold for pain, I occasionally use topical lidocaine cream prior to treatment for patients who request it.
Side-effects include swelling and redness which can last from 15 minutes to a few days days, depending upon how many linear veins are being treated and one’s genetic make-up. Swelling is most bothersome under the eyes, in people who have many veins in this area. Purpura, or bruising, can occur and is often hard to predict. It can last from four to seven days, and doesn’t hurt at all, but can be quite noticeable.
Every patient is different, and knowing what lasers and settings to use for each person requires lots of experience. Treating diffuse redness can pose more of a challenge even, than treating linear blood vessels. If one over-treats an area of diffuse redness, one can see the footprints of the laser treatment. Circular marks can be seen where the laser passed with over-treatment, so it takes skill to treat properly. If a patient has over-treated the treated area can give the illusion of scarring, but is simply over-treatment. Many of us with light, rosacea-prone skin derive our skin color partially from vascular tone or baseline redness. If a doctor over-treats the redness it can leave white marks that look like scarring, but in fact are the skin’s normal color, and requires more treatments to even skin color. There are more than a few medical conditions that result in facial redness and sun-sensitivity and can mimic rosacea. That’s is why it is ESSENTIAL to see a dermatologist prior to treatment, in addition to having an experienced medical person operating the laser for your treatment. Know who is behind the laser! Ask friends and other physicians who they would recommend for laser treatment.