Energy-Based Devices: Expert Shares Treatment Tips for Rosacea, Scars

Doug Brunk

March 08, 2021

When treating rosacea/telangiectasia with energy-based devices, the 595-nm pulsed dye laser (PDL) or the 532-nm potassium titanyl phosphate (KTP) laser are the first line options, according to a 2020 international consensus publication that Jeremy B. Green, MD, reviewed during a virtual course on laser and aesthetic skin therapy.

During his presentation, he also reviewed laser treatment of scars. "Erythema is an indicator of scar activity," said Green, a dermatologist in Coral Gables, Fla. "So, with flat, red scars, vascular devices are the first choice. If you're going to treat with multiple lasers in a single session, use the vascular laser first, followed by a resurfacing laser if needed. If you treat with a resurfacing laser first, you'll cause erythema and edema and you'll obscure that blood vessel target."

The manuscript, which was created by a panel of 26 dermatologists and plastic and reconstructive surgeons from 13 different countries, also calls for using scar treatment settings that are lower than those used for port wine stains, with mild purpura as the clinical endpoint to strive for.

Vascular lasers are also the expert panel's first choice when a scar is painful or pruritic, while the second choice is an ablative fractional laser with intralesional triamcinolone and/or 5-fluorouracil (5-FU). "If the scar is hypertrophic, I will combine a vascular laser, then a nonablative or an ablative fractional laser, then intralesional triamcinolone mixed with 5-FU," said Green, who was not involved in drafting the recommendations.

As for the first treatment of choice, 80% of the experts chose a pulsed dye laser, while others chose the KTP laser, intense pulsed light (IPL) and the neodymium yttrium aluminum garnet (Nd:YAG) laser. With regard to settings, when using a PDL and a 10-mm spot size, 41% of experts recommend a fluence of 5-6 J/cm2, 27% recommend a fluence of 4-5 J/cm2, and 27% recommend a fluence of 6-7 J/cm2. Pertaining to pulse duration, 50% favor 1.5 milliseconds, 18% use 3 milliseconds, and 18% use .45 milliseconds.

As for timing post surgery, 70% report treating less than 1 week after surgery and 90% report treating within 1 month post surgery. "I prefer to treat about 1 week after sutures are removed so the skin is re-epithelialized," Green said. "The bottom line is, with postsurgical, posttraumatic scars, once the skin is healed, the sooner you get at it, the better."


He also discussed the microvascular effects of PDL in combination with oxymetazoline 1% cream, an alpha1A adrenoceptor agonist, which is approved by the Food and Drug Administration for treatment of persistent facial erythema associated with rosacea. "This has been a hot topic lately," Green said. "When the studies were done for FDA approval, there was an observation that vasodilation occurs 5 minutes after application of oxymetazoline, so the venule diameter increases. Sixty minutes after application, vasoconstriction happens, which is the desired clinical effect for patients with facial erythema."

In a mouse study, researchers led by Bernard Choi, PhD, and Kristin M. Kelly, MD, of the Beckman Laser Institute and Medical Clinic, University of California, Irvine, found that the combination protocol of oxymetazoline application, followed 5 minutes later by PDL, induced persistent vascular shutdown 7 days after irradiation. Vascular shutdown occurred in 67% of vessels treated with oxymetazoline plus PDL at day 7 vs. 17% in those treated with saline plus PDL.

"This is fascinating," Green said during the meeting, which was sponsored by Harvard Medical School, Massachusetts General Hospital, and the Wellman Center for Photomedicine. "There is no publication I'm aware of in humans that has explored this timing, but I have used oxymetazoline in my clinic in patients with stubborn erythema and treated them with the vascular laser 5 minutes later."

In a separate open-label study of 46 patients with moderate to severe facial erythema associated with rosacea, researchers found that oxymetazoline 1% as adjunctive therapy with energy-based therapy was safe and well tolerated, and reduced facial erythema in patients with moderate to severe persistent facial erythema associated with rosacea. Energy sources used were the PDL, KTP, or IPL.

In a study presented during the 2020 American Society for Laser Medicine & Surgery meeting, researchers led by Pooja Sodha, MD, of George Washington University, Washington, conducted a pilot trial of PDL plus oxymetazoline 1% cream for erythematotelangiectatic rosacea. Between baseline and 6 months' follow-up the Clinician's Erythema Assessment score fell from 4 to 2.

"Of note, I would also throw the kitchen sink at these patients medically, meaning I love topical ivermectin 1% cream," Green said. "In some cases I'll even use oral ivermectin and an oral tetracycline class antibiotic."

He reported having received research funding and/or consulting fees from numerous device and pharmaceutical companies.

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