Rosacea Treatment Brings Hope and Relief
Harvey H. Jay, MD, in private practice in New York, NY, and has been an attending physician in dermatology for 40 years. Dr Jay spoke with The Dermatologist about recent advances in the field, the psychosocial impact of rosacea, and how he uses intense pulse light (IPL) in his practice to treat patients with rosacea.
Q. Rosacea can be a vexing condition. Do you find patients are often frustrated by the time they come to see you?
A. Most patients coming to see me for treatment of their rosacea are demoralized and disheartened. Their previous treatments, whether delivered by a dermatologist, aesthetician, from the internet or elsewhere, have usually failed to improve their rosacea or made it worse. They are usually desperate.
Two main issues account for the majority of problems. The first is that dermatologists frequently label serious and real symptoms of rosacea that involve burning, stinging, tingling, and/or major flushing as psychiatric issues. By failing to acknowledge these frequently disabling symptoms, patients are deprived of treatment with IPL, which I have used successfully for almost 20 years to improve or even clear these symptoms. These patients are discouraged and frequently embark on wasteful and frustrating courses of treatment.
The second and more frequent mistake that is made is in not appreciating the difference between long-term erythema or redness, and the short-term temporary residual erythema that remains after papules, pustules, or cysts resolve and which will usually clear without treatment. Applying one or more of the topical medications, or oral medications that prevent the papules and pustules, may only assist with preventing the lesions that produce temporary erythema, not with the long-term erythema and prominent blood vessels. I have found that IPL alone can routinely treat, improve, or even clear each of these aspects of rosacea. Rosacea’s permanent and temporary redness or erythema, blood vessels, papules and pustules, flushing, burning, tingling, stinging, and itching have all responded to IPL treatment.
In situations where the very sensitive skin of rosacea patients has prior to IPL already been irritated topically, this irritation must first be addressed before IPL can be administered to treat the underlying problem(s). Unnecessarily treating the erythema with topical medications, especially the extremely irritating gels, frequently exacerbates rosacea. IPL treatment must also be delivered gently and comfortably to ameliorate and not exacerbate rosacea.
Although laser treatment of rosacea can be successful, I prefer IPL for several reasons: First, I have used IPL for more than 20 years, and in my hands, I find it to be very gentle, effective, with very rare side effects, such as bruising. Second, many of my patients have had prior treatment with lasers, and report a high incidence of bruising, pain, and flaring of their condition.
Another reason for my new patients’ frustration is the many ineffective, expensive, and/or harmful products that they purchase, especially on the internet. Aside from the significant financial waste involved, these products discourage these people and even injure their very sensitive skin. Rosacea patients are frequently aware of which products (whether over-the-counter or prescription) have irritated their skin. We must take the time to listen to them and avoid reinjuring their skin. It is essential that any potential topical product be tested first on a small postage stamp size area of skin before being applied on a large area. Flexibility and caution are mandatory. Many gels specifically marketed for rosacea are too irritating for my patients. Topical steroids should be avoided when possible, especially for long-term use, because they can produce “steroid rosacea.”
Q. What therapies do you consider first-line treatment?
A. My suggestions for first-line treatments are: For papules and pustules and cysts: acne surgery, IPL (or laser); topical or oral antibiotics (oral for more severe cases or where there is severe skin irritation that prevents topical treatment). I do not recommend any gel-based topical product or any washes (eg, with benzoyl peroxide). In addition, I evaluate for iodide intake sensitivity (such as increased consumption of seafood, kale, or seaweed). For blood vessels (ie, telangiectasia) and also for permanent redness, I suggest IPL or laser. For temporary redness: I treat as papulopustular or cystic rosacea (see above) and wait to see if additional treatment is necessary and avoid sunburn or any irritation. I would use IPL or laser in the rare circumstance if quicker resolution is desired for this self-limiting problem. For flushing, burning, stinging, tingling, and/or itching, I perform a gentle IPL treatment approximately every 3 to 4 weeks. Cool water, applied as wash cloth compresses or in a baggie, can help relieve these symptoms. Direct application of ice is usually too irritating and should generally be avoided. Sucking slowly on ice chips or sipping cold water can help reduce the duration and severity of flushing episodes.
Q. Is combination treatment effective?
A. Combinations of treatments can frequently be necessary and helpful. In view of the sensitivity of skin in patients with rosacea, caution must be exercised in gradually implementing all treatment changes. I find that absent any condition such as skin irritation or tanning, starting with IPL and then supplementing with topical clindamycin 1% lotion (if needed) and/or oral doxycycline can accelerate the speed of improvement. Once clearing of papules, pustules, and cysts, tapering off the doxycycline first, and subsequently the clindamycin lotion is usually the best course of treatment. In general, having the rosacea patient minimize their topical products (whether they are prescription medications or over-the-counter soaps, or lotions) lessens the chance of their having a problem which will aggravate their rosacea and delay their improvement.
Q. What are some of the rosacea advances that you are excited about?
A.The most exciting developments in rosacea involve the new scientific understandings regarding the etiology of rosacea. Innate immunity with abnormal antimicrobial peptides, cathelicidins, and neurovascular interactions are shedding new light on rosacea’s molecular biology and the promise of better treatments to prevent and/or treat rosacea.
Q. Where do you see the future of treatment of rosacea?
A. In the long term, the scientific developments will hopefully translate into new and exciting treatments for rosacea patients. Better understanding of the genetic factors involved with rosacea, when combined with new methods of gene therapy may have a profound impact on the prevention and treatment of rosacea.
For the near-term, I see a new campaign to educate patients and dermatologists about the real and spurious treatments for each aspect of rosacea, including the serious and relatively unknown symptoms (such as flushing, burning, stinging, tingling, and itching) which are not imaginary, and which regularly respond to IPL treatment. I think there will be a cost and time savings for patients from avoiding heavily marketed but ineffective treatments, and the recognition that IPL treatment is a gentle long-term effective treatment for all aspects of rosacea (except for severe rhinophyma, which usually requires laser, cold-steel, or cauterization surgery). Insurance industry refusal to offer a treatment code for reimbursement of IPL or laser treatment of rosacea should be rectified to make this remedy affordable for all who will benefit from its availability.
In addition, I am currently working on a prototype for rosacea specific IPL devices for easy utilization by physicians, as well as devices designed for at-home self-administration by rosacea patients.
Q. What advice do you have for young dermatologists who are interested in the rosacea specialty?
A. I advise dermatologists who are interested in helping patients with rosacea to listen patiently and carefully to appreciate the major physical and emotional toll that rosacea exacts. Be prepared to be initially surprised by the devastating impact. Rosacea for many is clearly not just cosmetic. It effects all aspects of their lives: from changes in temperature associated with going from warm to cold or vice versa, from cooking in a warm kitchen, from going from one room to another at work, from accompanying children during outdoor or indoor activities, from any exercise or emotionally stressful situations such as giving a presentation or teaching, from being embarrassed or angry, from drinking any hot or spicy beverage or eating hot or spicy food, and from drinking alcohol, as well as many other scenarios. Their symptoms can be disabling and take a huge toll on their personal and professional lives.
Also, be ready for patients and their loved ones’ extreme gratitude when you validate their suffering and then improve their condition. I was initially amazed at how much they and their families appreciated my assistance and in the profound physical and emotional improvement that I have witnessed in them and their loved ones.
The challenges are real in approaching these frustrated and frequently disdained people and giving them hope and empathy. They frequently have lost hope and don’t fully believe your stories of past patient successes. Their skepticism is usually justified based on their past negative experiences.
Giving them hope and then actual relief that can last for months, years, and in some cases, probably a lifetime, are some of my greatest and most emotionally satisfying practice experiences.
For more information, please visit Dr Jay’s website www.rosacea.net.