1	Acne Rosacea IPL & Laser Treatment Options Lumenis User Group Malta November 2008 Dr Peter Crouch The Burghley Park Clinic & Great Western Laser Unit
2	The Conditions that are Rosacea Typical symptomatic presentations Red face alone Flushing alone Mixed Red face AND Flushing Oh and … (Not Rosacea)
3	Clinical streams…
4	Red face alone I first use Intense Pulsed Light Consent and test patch first Establish efficacy upon 4-6 week review Start conservatively Build up treatments Mix in photorejuvenation
5	Filter and fluence influence depth
6	“T.R.IPL.C” Three range I.P.L. with Clarithromycin 590nm 22 J/cm²1^st Pass 615nm 24 J/cm²2^nd Pass 90^o 695nm 26 J/cm²3^rd Pass 90^o Clarithromycin 250mg BD for two weeks Clarithromycin 25omg OD for two weeks
7	Orientation change
8	Selective Photo thermo lysis In order to target a specific tissue, one should select a wavelength which is strongly absorbed by a chromophore present in that tissue. Most medical laser applications depend on the absorption of laser light to heat the target tissue. To prevent undesirable thermal injury to adjacent tissue, light can be applied in suitably timed pulses related to the size of the target structure, according to the principle of Selective Photothermolysis.
9	Three Range Intense Pulsed Light With proper selection of the wavelength, exposure time, and intensity of the laser energy, the effect on the target tissue can be optimized and undesirable collateral effect on adjacent tissue can hopefully be minimized.
10	How do settings evolve? 590/615/695 nm 22/24/26 J/cm2 590/615/695 nm 24/26/28 J/cm2 560/615/695 nm 22/24/26 J/cm2 560/615/695 nm 24/26/28 J/cm2 515/615/695 nm 22/24/26 J/cm2 515/615/695 nm 24/26/28 J/cm2
11	Triple Pulses … why?
12	Thermal Relaxation Time The Thermal Relaxation Time ( t_r) of a given structure is the time needed for 50% of the heat generated by absorption of a pulse of energy to diffuse into the surrounding tissue and is proportional to the square of the diameter of the target structure.
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14	IPL Long term Results?
15	Medication I don’t pre-flush with anything other than the Zimmer cool air blower Post IPL treatment (not YAG) I prescribe Clarithromycin as an angiogenesis inhibitor Dosage:- 250mg BD for two weeks Then 250mg OD for two weeks (then stop) Note – this is not licensed for this indication
16	IPL resistant cases ? Consider Pulse Dye Laser Effective (in all but a few PDL resistant cases) Less even results IPL may even out uneven results after Pulse Dye Laser treatment even if the initial condition was resistant.
17	Flushing My face burns, heats up and “seems to swell…” Different triggers Time of day Hormonal cycle
18	We stumbled on something… Nd:YAG 1064nm is FDA cleared for photorejuvenation Some of our patients are inevitably those who present with rosacea and list flushing as a problem Some patients who opted for photorejuvenation reported that their flushing got worse for 2-4 weeks… BUT crucially, then reported that it reduced below baseline after 6 weeks… and wanted more Thx
19	Nd:YAG Short and Long term results?
20	How do we treat flushing? Nd:YAG 1064nm 4-6 passes 10mm spot size 50ms pulse width
21	IPL Vs Nd:YAG
22	Role of Pulse dye for Seb Derm Seb Derm can flare with IPL Tony Chu at The Hammersmith has been using Nlite Pulse Dye Laser for calming down Seb Derm The Nlite Chaser (2.5J/cm2 – single pass) is used to prevent a Seb Derm Flare next time
23	IPL may cause a flare this time so use Pulse Dye as a prevention for next time Pulse Dye treatment as “a chaser” is an investment for next time Its all the rage at the moment with our clients
24	How are we trying to make sense of all of this? I was recently asked to explain how I categorise patient factors (skin type), treatment aims, treatment response, long term outcomes and patient satisfaction when multiple conditions requiring different treatments are all present. It is no simple task. Sometimes I think we have invented a new language altogether. Although it is complicated, it attempts to assign numbers to subjective measures
25	We are developing scoring charts to help both us and patients chart their progress in a standardised way
26	Patient Satisfaction Overall
27	Relapsing Condition Outcome ?
28	Immediate Tissue Energy Tolerance
29	Immediate Treatment Response
30	We have started recording... FPST2 Skin type 2 FL3 Mixed flushing and basal redness SD2 Moderate Seb Derm TE1 Mild surface redness PI2 Moderate dispigmentation TE1:IPL2;ITET2;ITR2;PTE2;RCO1;PTE3;PSO3 Skin tolerated IPL well with little side effects and slight relapse, patient v. happy FL3:NDY2;ITET2;ITR2;PTE2;RCO0;PTE3; PSO3 Skin tolerated Nd:YAG well with little side effects and no relapse patient v. happy SD2:PDL2;ITET2;ITR2;PTE2;RCO2; PTE3; PSO3 Skin tolerated PDL well with little side effects but moderate relapse patient v. happy PI2:KTP-1;ITET-1:ITR0;PTE0;RCO NA; PTE-1; PSO3 Mild transient side effects from KTP, no response, innocent bystander tissue damage patient not happy with this treatment but is happy overall
31	The light responsive condition & light tolerant skin Whilst a patient’s skin may be light tolerant, the condition requiring treatment may not turn out to be light responsive. Often you can only reach the conclusion that a patient sadly has a condition unresponsive to IPL or laser only after test patching has established that the skin can tolerate the treatment and after the skin condition does not respond to the treatment. Patients may be able to tolerate one treatment modality and have a condition that is very responsive to, for example, IPL for rosacea but be unable to tolerate KTP laser treatment for pigmentation. Sometimes, one treatment modality is chosen, not because it is the most effective but because although it is only moderately effective it can be delivered as it is best tolerated.
32	Conclusion Rosacea is a very common condition It is not one condition Presentation is often symptom based Basal Redness Flushing Mixed picture Beware other conditions presenting as Rosacea Rosacea is treatable but be clear with patients what to expect and develop & stick to clear & logical protocols. Document contemporaneously.