Interview and followup with Dr Peter Crouch

Doctor photo

Dr Peter Crouch MB.BS.(T)GP. Section 12 Approved
General Practitioner & Forensic Medical Examiner (Principal Police Surgeon for Wiltshire)
Medical Director: The Great Western Laser Unit
Clinical Director: The Burghley Park Clinic
Office   +44    (0)1793 709580
Fax       +44    (0)1793 709581

Questions and answers 22 July 2005

Q. I was wondering if you could give a general grading to the efficacy of Lumenis One treatment on rosacea symptoms on a 0 to 10 scale with "0" being no improvement and "10" being complete clearance. For better clarity, please address the symptom clearance on the severity of the disorder. Thank you, Dr. Geoffrey Nase:

 MildModerateSevere
(a) Facial Redness875
(b) Facial Telangiectasia555
(b) Facial Papules864
(c) Facial Pustules222
(d) Facial Flushing875
(e) Facial Burning Sensations245
(f) Burning/Stinging234
(g) Under eye veins and bluish tint6*6*6*
(h) Facial Pores555

* N.B. I would not treat inside the orbit

Q. Do you advocate the use of multiple passes of varying wave lengths during a single treatment session? Thanks, Spav.

Thank you for your question Spav, Yes I do- multiple passes — as soon as I can be sure that the patient's skin can tolerate the IPL. We do up to 3 passes at different wavelengths (e.g. 695, 640, 615 or 590 nm) and rotate the treatment head 90 degrees to ensure even spread of energy to the skin so that lines are not left as the skin redness clears.

Q. First of all, thank you for contributing to our group. We all greatly appreciate you taking to time to talk with us. I'd like to ask you about your opinion of the future of IPL treatment for rosacea and flushing. With the promise new of interesting topical and oral drugs on the horizon, do you think there will be a place for lasers in 5 - 10 years time? If so, how do you think lasers will develop along side said medications? Many Thanks, Bob Bear.

Thank you for your question Bob, as an acne rosacea sufferer myself, I share your optimism that topical / systemic drugs may make laser / IPL treatment redundant in the future. I strongly suspect however that both are here to stay. Perhaps with better tolerated, more effective flushing agents, they will amplify the effects of the IPL so that fewer treatments are required and that the treatments are more comfortable and effective. An advance in the post treatment therapies (avoiding post treatment flushing & inhibiting the future growth of vessels) would be most welcome.

Q. Along these same lines, I understand there are two to three soon to be released upgrades or gadgets for the Lumenis One. Do you know what these upgrades are, have you tested them and do you think they will result in better treatment? Thank you, Dr. Geoffrey Nase.

Thank you Dr Nase - The software upgrade relates to an issue identified by early users of the Lumenis One and applies ONLY IF the practitioner does not re-check the energy settings prior to firing the Lumenis One. Any practitioner aware of the potential issue should be operating safely by following a checking protocol. All Lumenis One machines are being upgraded to remove the need to constantly recheck (at our clinic we will still continue to do the pre-fire check as it is good practice anyway). Patients should be aware of this and ask their practitioner — have you had the upgrade (and if not, are you aware of the issue and do you take steps to avoid it ?)

The Lumenis One already has an Intense Pulsed Light source, a diode laser (called Lightseer) for hair removal and an Nd:Yag laser head. This makes the Lumenis One an extremely versatile machine. The other optional "gadget" that is about to be added to the Lumenis One this autumn is the "Aluma" — this is a bipolar radiofrequency device that will heat tissue by passing radiofrequency energy between two electrodes on the tip of the device.

Q. How many treatments do your patients, on average need? What about touch-ups? Do you have any "resistant" or especially difficult cases i.e. patients who have had previous unsuccessful treatments or treatments that could be improved upon. Sincerely, Elizabeth

Thank you for your question Elizabeth, 4 or 5 treatments usually. Very severe / rapidly progressive rosacea needs more sessions. Touch ups are often required either six monthly (6 month intervals) or yearly. Some patients need no touch up treatment at all whereas others (usually with more sever / progressive rosacea need regular maintenance therapy).

Q. Dr. Crouch, do you ever pre-flush patients with topical or oral agents? If so, are you able to divulge what you use? Regards, Dr. Geoffrey Nase.

Thank you Dr Nase, Yes. I sometimes use topical niacin (I'm not a great fan of oral niacin because some patients feel dreadfully and uncomfortably flushed for ages after oral niacin). I find that cold air works particularly well on many patients ~ we have a special cold air blower which delivers cold air in a controlled flow and flushes even the most resistant vessels very nicely just prior to treatment

Q. Dr would you be willing to keep up with the ever-changing technology for rosacea? Laser manufactures are always upgrading; would you be willing to add proven and future rosacea lasers and IPL systems such as Cutera Laser (genesis laser) or the new Sciton BBL and super yag (www.sciton.com)? Thanks, AleCashley.

Thank you Ale, We would of course be willing to explore upgrading if we were aware of anything better for our patients. We invested in the Lumenis One for just this reason.

Q. Hello Dr. Crouch, I'd like to thank you very much for agreeing to participate with this forum. A question I have asked many laser specialists over the phone, in trying to decide if I should see that doctor, is, "How effective are the treatments at reducing flushing?" Oftentimes, and especially a few years ago when there were a lot of aesthetic facial clinics popping up, I would hear that a given clinic treated rosacea. But, more often than not, "treating" rosacea meant clearing telangiectasia, redness, and reducing acneform lesions. Unfortunately, one could come away with pinker-looking skin, but the flushing was still present, and sometimes not affected at all. With the newer generations of lasers and protocols, do you feel that physicians are more able to treat the vessels which are responsible for flushing, which is the heart of our disorder? What do you consider to be the best protocol for treating flushing with laser? Thank you very much for your time. David

Thank you for your question David, I think the triple pass using the Lumenis One IPL at different wavelengths (695, 640, 615 or 590 nm) is the most effective at treating redness and flushing. Avoidance of flushing after the treatment is important (though not always possible). For flushing that is resistant to IPL ( not all patients will need this), I'd recommend desensitisation with the Nd:Yag laser at 1064nm.

Q. Thank you Dr. Crouch for your time. I was curious how often you perform laser treatment on rosacea sufferers with darker skin tones (skin types 3, 4, & 5) and what results you see with these patients? If you do, how does your protocol change? What approaches to treating these patients do you take? Thank you, Carlos

Thank you for your question Carlos, I am very, very cautious about treating anyone with pigment in their skin as the IPL ( and some types of lasers) can remove the pigment OR increase it. I subscribe to the "Do no harm" school of medicine. I generally recommend erring on the side of caution in patients with darker skin pigment — for example the Nd:Yag laser can be much safer in patients with skin types IV, V and VI.

Q. Dr. Crouch, I would like to echo the thanks that others have offered for your willingness to participate in our forum. I'm wondering, along with those who have already expressed this, about facial procedures you would NOT recommend for rosacea sufferers. I have read that microdermabrasion as well as dermabrasion are not suitable for rosacea sufferers. Is this correct? If so, what do you recommend for rosacea sufferers who would like to get rid of deepening lines near the lips (not the nasolabials but the tiny vertical "cracks" that form on and near the lips as a person ages). Also, I have been looking for some time now for a doctor who can perform the specific treatment Dr. Nase recommends using a YAG 1064 for purposes of reducing facial sensitivity. Is this something you do? Thanks again for your help. Nova

Thank you for your question Nova, I would not recommend dermabrasion in any event (certainly not until after treatment to reduce the rosacea). Dermabrasion would run a significant risk of breaking any fine superficial blood vessels and the result would not look good! I personally recommend Erbium Yag (2490 nm) skin resurfacing for the condition you mention. We have several Nd:Yag lasers that can be used to reduce facial vessel sensitivity and for some patients who are very trigger sensitive, 1064nm Nd:Yag works well. We have to remind patients that they are looking for reduction in sensitivity — (for the reduction in overall redness we would look to IPL).

Q. I imagine that many enter your office red-faced and unhappy. You will meet with a sufferer on perhaps six or seven occasions over as many months. A number will experience significant reduction in their symptoms. Tell me about their changes in body language, in outlook and in mood over that time. Thanks, GJ.

Thank you for your question GJ, often eye contact is not good to begin with and one can only suspect that self esteem is at rock bottom. What we tend to notice as treatment improves the condition is that self confidence returns and more eye contact is made as the body language improves e.g. the head is held "higher". Some patients who grow their hair longer to hide their face start to wear their hair tied back or go for a shorter hair style! Most patients report that their mood lifts as treatment progresses. Sometimes patients burst into tears for a variety of reasons ~ not all of them bad — sometimes they are just happy tears of relief and betray many years of pent up emotion and frustration with the condition.

Q. Do you ever try to treat seborrheic dermatitis with laser or IPL? Thanks, Winnie.

Thank you for your question Winnie; I personally don't treat seborrhoeic dermatitis with either the laser or IPL. I haven't personally seen any good evidence that this works well but would remain open minded.

Q. Dr. Crouch, we have been encouraged to ask personal questions so here goes: Personally, I have had 9 unsuccessful IPLs with the 560 filter (when I had very mild rosacea). Now that my rosacea has progressed I have had 8 reasonably successful v-beams. I say "reasonably successful" because the veins/redness on my chin go away straight after the laser but always return after a couple of months. Do you think that the Lumenis One machine might be able to help me eradicate this problem once and for all and what settings would you recommend? Thank you for all your assistance with any and all of the questions that you answer! Thank you, Elizabeth.

Thank you for your question Elizabeth, I would recommend pre-flushing (with a topical agent or cold air), a blend of 2 or 3 IPL filters (695, 640, 615 or 590 nm) and strict adherence to post care medication and avoidance of flushing ( if practical to do so). As I don't know your medical history etc. I don't yet know if it would be safe for you to take it but I would normally recommend clarithromycin post treatment (a higher twice daily dose for 2 weeks then a lower once daily dose for a further 2 weeks).

Q. I have "seborrheic dermatitis" of the scalp, too, which seems to be just the same as my face symptoms, as I have scalp flushing, papules along the hairline, a swelling on top of the scalp which comes & goes, greasiness, and all-over hair thinning. Is IPL on the scalp impossible due to the danger of destroying hair follicles? Irish Genes.

Thank you for your question Irish Genes, the skin of the scalp behaves very differently to say skin on the face and it is generally thinner. There would be a significant risk of damage to skin and hair follicles so I would urge great caution before applying IPL to the scalp.

Q. Thanks Dr Crouch for participating here! This is a great thing. So here goes - Is there anything you do to specifically treat large pores? Does this help oily skin as well? (they seem to go hand in hand) Also, do you ever use the YAG 1064 along with IPL? Library Lady.

Thank you for your question Library Lady, I think that the Erbium Yag Laser can be quite good for helping to reducing pore size. Thermage (radiofrequency) may be actually quite good for treating large pores as it heats the "sweat pore" unit - but it is quite expensive and not the only option. We are currently evaluating a Q-switched Yag laser that shatters carbon paint held in an oil suspension (so it penetrates the pores and when it is energised encourages them to close). I would not encourage dermabrasion as this would risk breaking the blood vessels.

Q. Many rosacea sufferers complain of red ears that flush and burn. Do you treat ears for redness and if so, do you worry about damaging the thin layer of cartilage. Thank you, Dr. Geoffrey Nase

Thank you Dr Nase — great question, I think that the risk of side effects associated with treating the ears make ear treatment so challenging as to be an almost strict contraindication to therapy. The cartilage is very prone to heat damage and the skin over the ears is quite different in the way it reacts to IPL. Unless ears are a really high priority, I would urge extreme caution before going down that pathway.

Q. Dr. Crouch, how do you go about treating the big blue veins on rhiniphymatous noses without causing an indentation in the skin after the vessel is removed? Sincerely, John

Thank you for your question John, I prefer to use the Lyra or Gemini (1064nm NdYag). It has a cooled sapphire window which directly contacts with and protects the skin whilst the laser beam travels through the window and coagulates the vessels. These need very gentle treatment to avoid the indentation you mention.

Q. Dr. Crouch, if you are treating a severe case of vascular rosacea and are only getting minimal improvement after 10 to 12 treatments, do you have anything in your bag of tricks that you like to try? Understanding that this is only an answer to a question and not medical advice to be toyed with. Any techniques, thoughts or even speculation would be wonderful. Sincerely, Dr. Geoffrey Nase

Thank you Dr Nase, Yes — then I turn to Pulse Dye Laser. We have several in the clinic (which we use mainly for inflammatory acne, portwine stain and vascular scar reduction) but there is very little to choose between them for this indication. Sometimes a few passes of the pulse dye laser at 585 or 595nm does the trick with very resistant cases but to be honest, cases like this are few and far between mercifully.

Q. How do you go about treating papules with Lumenis One? Do you like to treat them when they are out or do you wait until they are under control. With regards to your answer, what is your reasoning. Thank you, Irish Genes.

Thank you for your question Irish Genes, I have to say that I don't wait until papules are under control — I treat them at the same time with IPL as the IPL does bring them smartly under control in my experience. In contrast, pustules don't normally respond to IPL — I would normally advise topical antibiotics first and then, when they are under control then switch to IPL.

Q. Thank you Dr. Crouch. In an effort to continually improve, are there any recommendations that you have for our forum on any aspect of this section  less questions, leave some narrative space for the physician to talk about one aspect of his treatment that has really made a difference, more challenging questions/less challenging questions? Thank you so much. Dr. Geoffrey Nase.

I spend a lot of time in Court (as a professional / expert witness I hasten to add!). I think that sometimes the question I would like to be asked goes something like this&

Is there something I didn't know to ask, that if I had known to ask you, would have helped you to help me better? I think sometimes by asking the Dr what question(s) the questioner should have asked to get the most useful/helpful answers might provide some useful answers.

The question I would have liked to have been asked was

"What was it that stimulated your interest in your field of expertise?"

I'd have replied :-

"Having Acne Rosacea myself and then finding that there was a set of treatments that really worked was the key stimulus — as a physician — finding something that could help others in a way that was easy to identify with personally is very rewarding both personally and professionally".

Followup questions 26 July 2005

Q. If a patient comes before you who has no sign of rosacea outwardly ie; has no diffuse redness, telangiectasia or acne lesions and yet suffers regular (daily), painful bouts of facial flushing in response to temperature fluctuations, emotional turmoil, stress and tiredness - what would be yr treatment protocol for such a patient and would you still class these symptoms as rosacea? Thank you very much Dr. Crouch, bcoz-yr-gorgeous.

Thank you for your question bcoz-yr-gorgeous, sure – I would attempt to flush them with our cold air blower technique and then use either the Lumenis One IPL triple filter technique or, the 1064nm Nd:Yag to desensitize the vessels. I generally prescribe clarithromycin 250mg twice daily for two weeks then once daily for two weeks afterwards and urge avoidance of flushing if possible.

Q. Is the cost of the laser treatments something your clinic recognises as being particularly difficult for those whose rosacea has affected their earning potential?

It concerns me that prices are prohibitive, and seemingly more aimed at the purses of those who would consider the treatment for cosmetic rejuvenation only.  I would dearly love there to be a sliding scale in place for those who come to you for rosacea treatment, where if you can prove you are a low earner then an appropriate discount could be pro-offered.

So many people, myself included are caught in a catch 22 where their rosacea symptoms are preventing them from being able to pursue a career and yet their lack of earnings are preventing them from earning enough money for treatment for their symptoms and round it goes.   I wonder if physicians are aware of this? Thank you very much Dr. Crouch, bcoz-yr-gorgeous.

Thank you for your question bcoz-yr-gorgeous, I do recognize this and undertake a limited amount of pro-bono work when I feel that I have the opportunity to offer treatment to someone for whom the cost would otherwise be prohibitive. Last week and this week I am seeing 20 patients. Just this last week, I saw and treated a university student free of charge. Tomorrow, I am seeing two patients free of charge – one a student investing in the cost of traveling from abroad and another patient who has been burned by IPL before but keen to try the Lumenis One. The treatment is sadly not yet available on the National Health Service but together with NHS Dermatologists, I am keen to promote Laser and IPL treatments on the NHS. This would bring the therapeutic benefits of this light based technology within the reach of all, regardless of the ability to pay – this is a fundamental principle of the UK National Health Service.

Q. Dr. Crouch, some rosacea sufferers have coexisting disorders such as rosacea with acne. Are you able to alter sebaceous gland activity, lessen acne symptoms so the patient does not have to use irritating acne products, or use any personal approach to address this common combination? Do you like the clearlight on the Lumenis for acne treatment – in theory or in practice? Thanks again, Dr. Geoffrey Nase.

If we are treating acne with rosacea then I promote concomitant use of the NLite Pulse Dye Laser (585nm) but in acne treatment (not in vascular mode). In this mode, it is suggested that (at laser fluences lower than those that would risk purpura), the laser light triggers a change in the immune system leading to a sustained improvement in inflammatory acne. I believe that IPL and NLite are a logical combination in acne and acne rosacea.

We used to use the Lumenis Clearlight but found it to be ineffectice – I have since re-evaluated the Clearlight's use after attending several fascinating presentations on photodynamic therapy presented at this year's American Society of Lasers in Medicine and Surgery conference in Florida. The photodynamic therapy (applied topically to the skin) can be activated at the specific wavelength of the intense blue light emitted by the Clearlight.

Q. We have a lot of rosacea sufferers that may have a variant of rosacea called Keratosis Pilaris. The backs of their arms are affected by bumps and redness; often times it extends up into the cheek area. This is very hard to treat with laser based on patient reports, but there seems to be no available solution for these sufferers. This is not a rare condition and is a subject discussed quite often. Do you have any experience with treating KP of the face or arms? Do you know what the pathogenesis of the disorder and new treatments available? Question submitted by Dr. Nase for ESFB Board Members.

I have little experience treating KP as it is both relatively rare and I tend not to recommend treatment with laser / IPL as nothing we have to offer seems to help with Keratosis Pilaris. My heart goes out to these patients as I know of nothing that helps particularly ~ perhaps something will come along one day.

Q. When treating moderate to severe rosacea sufferers, when do you put down the laser machine and tell the patient that is laser resistant, this technique is not going to work on your individual case? 15 treatment, 25 treatments, or never? Sincerely, Big John.

Thank you for your question Big John, I think there comes a time when both patient and physician comes to realize that, whilst however well intentioned, treatment has nonetheless resulted in "a noble failure". I strongly believe that the physicians ethical responsibility wherever possible is to "Do no harm". This applies to "fiscal injury" also and, if the patient has no chance of improvement then, in my humble opinion, a truly ethical practitioner should not continue to

Q. You mentioned that you have/had acne rosacea. Your photo obviously shows no signs of the disorder. Noting that all cases are different, are you able to tell us the approach(s) you took to clear your symptoms? Did you also experience flushing and if so, was this successfully treated. Regards, Dr. Geoffrey Nase.

Thank you Geoffrey - I do have acne rosacea — I am grateful to my colleague, Dr June Morris who used our equipment to treat my rosacea. Our laser nurses Carol and Christine provide me with intermittent (six monthly top-ups). I can say that this has absolutely taught me what old and new technology feels like to be on the receiving end of. The manufacturer's manuals say — the pulse of the IPL is like being snapped with an elastic band. I say "& Hello! - the old quantum and vasculight felt like being spattered with hot chip fat". The Lumenis One still feels hot for a fraction of a second but the cooling is very much more sophisticated and really cuts down on the discomfort. I used to flush terribly — I used to worry that people would think I looked drunk when, as a Principal Police Surgeon (Forensic Medical Examiner), I am generally tee-total. I used to flush with cold air and spicy foods but not any more. I know when I need a top up now when the redness starts to gradually appear on my cheeks on either side of my nose. I hope to avoid rhinophyma at all costs. Usually one session now every now and then seems to keep things nicely under control.


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