Interview 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

Disclaimer

Any advice or information provided here does not and is not intended to be and should not be taken to constitute specific medical advice given to any group or individual. This general advice is provided with the guidance that any person who believes that they may be suffering from any medical condition should seek professional advice from a qualified, registered/licensed physician who has the opportunity to meet with the patient, take a medical history, examine the patient and provide specific advice and or treatment based on their experience diagnosing and treating that condition or range of conditions. No general advice provided here should be taken to replace or in any way contradict advice provided by a physician able to meet with the patient, take a medical history, examine the patient and provide specific advice and or treatment based on their experience diagnosing and treating that condition or range of conditions.

Questions and answers May 2011

Shantelle

Hi there Dr Crouch I have both Rosacea and Lupus (Derm confirmed mild cutaneous lupus, but Rheum team monitoring as well incase of onset SLE). Even though Lupus is the most concerning health-wise, my Rosacea flushing/redness actually has the most effect on me. I am also eleven months post-Accutane, and currently on Plaquenil and Doxycycline. I am extremely photosensitive. In your opinion, should I be on the safe side an avoid lasers to help with the Rosacea symptoms? or are some lasers safe enough nowadays for me to perhaps consider it in my situation? Many thanks in advance, Shantelle

Dr Peter Crouch (↑Disclaimer):Dear Shantelle, Thank you for your question. Personally, I think if you are extremely photosensitive, I would steer clear of light based treatments until the photosensitivity settles and then consider light based therapy only if other options e.g. medication is not helpful. I would advise any patient with light sensitivity to exhaust most other viable non-light based options before risking photosensitivity.

Flemmo

Dear Dr Crouch, I have both rosacea and seborrheic dermatitis. There are very few treatments out there that treat both conditions. Very often, treatment for one condition aggravates the other. I know one approach is low level PDL, but I've also read Sodium Sulfacetamide based facial washes have been used in America for years, with largely very positive results. For some reason Sodium Sulfacetamide is not available on prescription in the UK. Do you know why this is? Is it something that could become available in the future?

Dr Peter Crouch (↑Disclaimer):Dear Flemmo, Thank you for your question. I don't believe that Sodium Sulfacetamide is available on regular prescription in the UK (it is not listed in the British National Formulary for example). Not all medicines are. Some dermatologists may instruct pharmacists to make up special preparations but it is not mainstream therapy. A dermatologist may be in a better position to answer but I haven't prescribed it in 20 years of practice.

Mattdog323

ive had ten ipl treatments with the lumines one over the past year and have improved my skin texture ten fold,its funny how some times the less aggravated treatments have been the best,Do you stand by the fact of, deal with it I'm blasting away? have you ever had success in treating the patient on the same settings time after time?Do the settings always have to be raised to get rejuvenation or have you found that adequate(semi high)settings performed on a regular basis keep on rejuvenating?? have you ever successfully put kprf into remission??? that's the big question I'm after,As kprf has been well documented to have worse cases than rosacea,Do you believe in remission(bold question) personally i think its a myth. sorry dr crouch ten questions in one !! wahoo!

Dr Peter Crouch (↑Disclaimer):Dear Mattdog, Thank you for your question(s!). I think that moderate energy settings provided that the progress is steady and sustained (no roll back due to angiogenesis) albeit slow but steady forward progress is something that experienced patients are generally very happy with. I think that sometimes the temptation is to try for faster progress and higher energy levels and this isn't always the best strategy in the long run. I hope that this makes sense. KPRF is notoriously difficult to treat with IPL and I advise patients with KPRF not to expect too much from IPL (but the 'photorejuvenation' is usually very welcome).

Mrsmoof

Dr Couch. My main triggers are artificial lights (fluorescent lights, computer screens, tv's, etc) and my skin will burn and get red. I currently take Minocycline (100mg 2x daily) and use Metrogel and Sodium Sulfacetamide. I have doing this treatment for 7-8 months. Have you treated others with similiar triggers/symptoms? If so, what works? I welcome all suggestions, etc... Thank you! Doug

Dr Peter Crouch (↑Disclaimer):Dear Doug, Thank you for your question. I generally advise those with light based triggers (distinct from those with photosensitivity) to consider the same Nd:YAG laser approach we have found has been helpful with patients with flushing. Many patients also report that low level LED light therapy can be helpful when they are troubled by these triggers.

phlika29

Dr Crouch, Many thanks for taking the time to answer our questions. I am going to ask the same question I usually do: are there any new laser/IPL advancements that rosaceans might benefit from? any new protocols? and finally any new non laser/IPL treatments that excite you

Dr Peter Crouch (↑Disclaimer):Dear Phlika29, Thank you for your question. I'm always scanning the horizon for new treatments and clinicians are always keen to adjust protocols if we find more effective treatments through research or experience. I can't say that I have found there is anything much new for rosacea in terms of technological advances. At The Burghley Park Clinic we have continued to use virtually the same protocols for rosacea for the past 3 years and with careful patient selection we find that very few don't benefit from an improvement in their most troubling symptoms. We can't treat everyone who presents (expecting to be able to do that or not adjusting patient's expectations appropriately would be unrealistic and inappropriate given the challenge that rosacea represents).

polster

Dr Crouch, 1. What are advantages and disadvantages of IPL vs. VBEAM Perfecta lasers? 2. any specific sunscreen and any over the counter vitamins/ supplements you can recommend for individuals with hypersensitive skin (redness, eczema, acne, etc..)

Dr Peter Crouch (↑Disclaimer):Dear Polster, Thank you for your question. I think that what you are asking is for a comparison between two different technologies: a) Intense pulse Light on the one hand & b) Pulsed Dye Laser (e.g. VBeam Perfecta being one particular brand of pulsed dye laser). IPL can't treat all cases of redness but when it does so tends to produce a more feathered out (smoother) result compared to Purpuric (Bruising) Pulsed Dye Laser as there is less of a step off with IPL compared to laser. Some pulsed dye laser treatments at lower energy levels in non-bruising (non-purpuric) mode or with slightly 'unfocussed' beam profiles can try to get away from the punched out look associated with purpuric focussed treatments (but then the effectiveness can drop away). I usually start with IPL and resort to Pulsed Dye Laser for resistant cases (often returning to IPL to feather out any irregularity in colour that results from purpuric laser treatments). Purpuric pulsed dye laser treatments can cause a form of hyperpigmentation which, whilst normally temporary, can be worrying and troublesome for patients especially if not expected. IPL can often help with this if this is prolonged or particularly marked. Sunscreens - I advise go by the standardised SPF (sun protection factor) for protection effectiveness but when it comes to skin sensitivity to topical products is so 'personal' mostly my advice is try a little on a test patch and stick to brands that you know and trust based on experience.

jlb2010

Dr. Crouch, I have had Rosacea for the past year and it has progressed very fast. I've had 4 Vbeam treatments every 4-5 weeks apart for the past few months. Recently, I did a purpuric VBeam at the advice of my derm. It has left me a mess! I have tons of hyperpigmentation all of my cheeks (about the size of a softball) and it has left me very flushy. My question is this: 1) will this hyperpigmentation truly go away on its own and 2) could I have made my rosacea worse since I am way more flushy (I am now 6 weeks post-op). I am so scared that I've made it worse. I barely flushed prior to t his treatment and now I flush constantly. How long to settle down. 3) I am not having much luck getting my derms to prescribe any flushing medicines - do you have any advice for convincing them that it is safe? Thanks so much for your time!

Dr Peter Crouch (↑Disclaimer):Dear jlb2010, Thank you for your question. I think that 6 weeks may still be early days for any hyperpigmentation to settle (hyperpigmentation does usually settle given time but it can take several months and sometimes IPL can help with a particular type of hyperpigmentation called haemosiderin staining if that becomes a problem). Your dermatologist should best be able to advise knowing how long it has taken for other patients they have treated. I tend to use laser treatments rather than medicines for flushing but drug therapy has a well established role in treatment of flushing.

Alba

Dear Dr. Crouch, 1st, thank you for taking the time to answer our concerns. I've had 3 IPL treatments in the past year and 1/2. They have helped with my redness and burning on my face. But my ears flush terribly. My derm has been afraid to try the IPL on my ears but the last time I spoke to him he said he would try to do a patch test. Do you now recommend IPL on the ears? Is there anything you think might help with the ear flushing? The last IPL I had was at a stronger setting, I noticed that after that IPL my nostrils insided were more dried and then my nose was flushing more. Does the IPL have anyting to do with this? Thank you again for all your help and attention. Alba

Dr Peter Crouch (↑Disclaimer):Dear Alba, Thank you for your question. I personally don't recommend IPL on the ears. Ear flushing in my experience is normally better first addressed with medicines rather than IPL/laser. IPL can reduce pore size and affect the sebum (oil) production of the skin over the treated area but in my experience this doesn't normally affect the inside of the nose.

Runcamirun

Questions about facial vein treatment in SF Hello Dr. Crouch, Thank you for taking the time to answer my questions. I am a 23 year old with a very fair complexion and mild to moderate rosacea (depending on the day). I flush easily and frequently which is quite embarassing but my main concern is visible facial veins around my nose and on the apples of my cheeks. I have been considering pursuing treatment for a while (IPL, NDYag and/or Vbeam) but keep reading differing opinions in terms of which treatment is most effective. If you could please answer the following questions I would be very appreciative: 1. Which treament would you recommend as providing the best and most long-lasting results in reducing facial veins (and to some extent large pores present in those areas as well)? 2. Do you have any recommendations regarding the removal of leg veins? Which procedure(s) would you recommend? 3. Could you please recommend dermatologists in the San Francisco Bay Area who could perform the treatment procedures you recommended? I am new to the area and in need of referrals. Thank you! Camille

Dr Peter Crouch (↑Disclaimer):Dear Runcamirun, Thank you for your question. IPL and Nd:YAG would seem to be the best options. NdYAG for the prominent well defined blood vessels and IPL for generalised redness and larger pores. I cant really recommend any clinicians in your area but you might like to check the physician locators on www.skinandhealth.com and www.laserscope.com for physicians near you who have the Lumenis One IPL and Gemini lasers.

liss

Hi Dr Crouch, I suffer from flushing and redness on my cheeks and nose and im thinking of having IPL done,I have fair and quite sensitive skin. What settings would be best for my face? also could you recommend anyone who is experienced with rosacea and IPL machines, like yourself but in the licolnshire area? thanks..

Dr Peter Crouch (↑Disclaimer):Dear Liss, Thank you for your question. I would suggest very conservative settings initially (test patching is always a good idea in my experience) to check that you have both a light responsive condition AND light tolerant skin. I don't know anyone specifically in the Lincolnshire area (it may be that there are practitioners near you) I couldn't hope to meet everyone but the website www.skinandhealth.com has a physician locator which is updated regularly and you might find tapping your postcode / area into there helpful if you are looking for IPL practitioners).

sparrow-legs

Hello Dr Crouch, I hope you are well, and would like to say thank-you for doing this Q&A session. I have a question about IPL recovery: I find it almost impossible to avoid flushing during the first few days following my treatment. Will this significantly affect the outcome? After a couple of weeks of flushier, more reactive skin, I believe I am now seeing the benefit of my fourth IPL. My skin seems calmer and paler, but I can't help but wonder if I would see even more improvement if I managed to prevent flushing in the post-treatment period. What are your thoughts on this? Also, as someone who is hoping to get into medicine myself, I am curious to know if there is much interest in rosacea in the medical community (from what you have seen). Personally I have not perceived much interest at all. The GPs I have seen have always somewhat dismissed my concerns about my skin, implying that there are much worse things to have (which I never found particularly helpful!), and friends already in medical school seem to have very little interest in dermatology in general. Thanks again Helena

Dr Peter Crouch (↑Disclaimer):Hello Sparrow-Legs, In my experience, I don't think that strict flush avoidance either a) is practical or b) significantly affects the outcome post IPL so I advise patients not to worry too much about this post-treatment. I think that it is important to normalise post treatment and to allow the skin to recover and adjust to frequently encountered triggers post treatment. There is a helpful paper published by Colin Dahl from Australia I often recommend A Practical Understanding of Rosacea. I think that rosacea is certainly well known about in the medical community but it is one of many thousands of discrete conditions. Most practitioners can provide good general advice but problem cases that don't respond well to general advice probably are best addressed by practitioners who see a lot of cases and have the core and case dependent skills to give specialist advice re an area they concentrate their clinical practice experience within.

Samj202

Hi Dr Crouch I have got a few questions for you, so here goes...... 1) I have had 4 Lumenis One IPL's over the past 3 1/2 months, the filters they used on me were the 515, 560 and 590 with two passes per session. As far as redness goes i have noticed quite a big improvement but the flushing still remains. When i asked the nurse if she could start using the 615, 640 and 695 filters on me to start targeting the deeper flushing vessels they were very hesitant and said for Rosacea that they dont use anything deeper than a 590 except if you are skin type V. I managed to talk them into using the 615 on me but the nurse said she had to put me in as skin type V so she could use that filter. So my question is, have you heard of any other laser clinics that have this approach using only the top 3 filters and do you think i am wasting my time going back there if they dont go any deeper??

Dr Peter Crouch (↑Disclaimer):Hello Samj202. I tend to use 590, 615 and 695 filters for most patients. The Lumenis One does come with inbuilt protocols for single passes and it may be that the operator is adjusting your skin type to match the machine protocols.

2) My next question is, what filters are the best for treating the blushing vessels and what joules, pulse delays etc would you use? And also how would you get those vessels "open" before treatment?

Dr Peter Crouch (↑Disclaimer):I have published our protocols at www.triplc.info and I find that , if required, cooling the skin first with an air blower and then letting the skin warm up naturally can induce a good blush.

3) As far as lasers go, in your opinion is the Lumenis One IPL still the best laser for treating redness, flushing and blushing? Or are there some new lasers out that are more effective?

Dr Peter Crouch (↑Disclaimer):Just for clarity, IPL is a form of intense pulsed light (not a laser) and the main difference between an IPL device and a laser (which emits a pure wavelength) is that IPL machines output a filtered blend of many wavelengths and these are absorbed by blood vessels of different sizes and at different depths. IPL is usually best for treating redness. Other devices (e.g. the Nd:YAG Laser) might be better suited to treating specific blood vessels or some specific types of flushing.

4) What are some other lasers you would recommend for treating Rosacea if the person doesnt have access to a Lumenis One?

Dr Peter Crouch (↑Disclaimer):I use a Nd:YAG laser (a Gemini to address flushing and a pulse dye laser (an Nlite) for people with resistant cases.

5) If the flushing and redness aspects of Rosacea are under control does that reduce the chance of developing Rhinophyma or is it something that can progress at anytime or stage of Rosacea?

Dr Peter Crouch (↑Disclaimer):I strongly suspect that we truly don't know the answer to your question (and I personally suspect that treating rosacea in the early stages probably makes little or no difference to the development of rhinophyma which is thankfully a rare outcome)

6) After the damaged blood vessels are destroyed by either the IPL or PDL do they grow back? If so how long does it take before they do? And do they grow back normal like in people without rosacea? Or do they grow back and automatically become hyper-sensitive?

Dr Peter Crouch (↑Disclaimer):The damaged vessels probably don't repair and grow back but new vessels can develop, particularly if the treatment fluences are high. We try to avoid this process (called angiogenesis) by treating at more conservative settings and by using a triple pass technique.

7) What is your opinion of the Polaris (ELOS) laser for the treatment of redness, flushing and blushing? Because as i mentioned in one of my previous post's that if the the people that are treating me at the moment with the Lumenis One IPL won't go any deeper to target the flushing i am going to try some different places/lasers to try get the flushing under control. The website of the place that use the Polaris laser is www.2lookgood.co.nz. So i was just wondering if you have ever heard of or used the Polaris laser and what your thoughts of it are?? Any info would be greatly appreciated. Thanks

Dr Peter Crouch (↑Disclaimer):Sam Hello Sam. I haven't seen any specific evidence that combining laser light and radiofrequency energy (as the Polaris does) conveys any specific benefit in the treatment of rosacea.

SimQue

Greetings... Hello Dr. Crouch. I am undergoing treatments with Candela's VBeam Perfecta for my permanent redness on cheeks and especially nose. The skin on my cheeks and nose have also thickened a lot. My doctor is very nice and knows what he's doing. My first VBeam treatment I think the laser settings were: 7.5 joules. 6 weeks after this treatment I had not experienced any kind of improvement... My second VBeam treatment I told the person whom performs these treatments on me that: "I have not experienced any improvement from my first VBeam treatment". So, he cranked it up a few notches. (from 7..5 J - 9.5 J... Something like that). Now it has been exactly 15 days since I had my second VBeam and the redness on my cheeks and nose has gotten worse and even more permanent, and I tend to flush ALOT easier. I really want to continue with my laser treatments, but it has only gotten worse than it used to be. Is this normal? When will I experience improvements concerning my redness? Should I go for a Purpuric Treatment next time, because I have heard that this much more efficient, but the "downtime" is a lot longer...? Please respond.

Dr Peter Crouch (↑Disclaimer):Hello SimQue, Thank you for your question. It is normal to experience increased redness and flushing in the aftermath of pulsed dye laser treatments. It is important to remember that the effect of Pulsed Dye Laser treatment fluences are not linear, the behaviour of the pulsed dye laser can step change quite dramatically as the fluence increases. I would rely on the experience of your treating practitioner, it can take 6-8 weeks in my experience for laser treatments to settle down so it's almost certainly too early to judge fully how your skin by 15 days post treatment.

Souris24

Dr Crouch, I've had very mild rosacea for 2 years with only a couple of bumps here and there, once in a while. I have been using RLT for about 3 months and the flushing of my cheeks has decreased to almost non existent but, strange enough, it increased the flushing of my nose a lot, so I stopped. My nose is now flushing almost systematically in the evening, after diner. I do not have permanent redness yet but still, I am clearly getting sort of pinkish. So, my question is : Would lazer treatment work well on a skin which isn't really red and would it stop the flushing or should one do lazer treatment when really red only ? Also, it seems to me that here, in France, most Derm have KTP lazers. Would that be appropriate for flushing? Else, do you think a medecine like clonidine could be a good alternative to lazer to prevent more redness from flushing. Thank you very much for offering your time to answer our questions. Marie

Dr Peter Crouch (↑Disclaimer):Hello Souris24, Thank you for your question. Nd:YAG laser treatments for flushing can work on the areas which aren't red wherease IPL relies on pigment (to help deliver targeted energy to the blood vessels causing the redness). KTP in my experience isn't normally very good for flushing ( often best for targeting unwanted pigment). Anti-flushing medicines like clonidine can provide a useful alternative to laser or IPL. You should take advice from and be guided by an experienced practitioner who can advise what treatments are best for you to try to tackle the flushing.

flushingmad

Flushing Medication Advice Dr. Crouch, Thank you so much for taking the time to answer our questions. It is greatly appreciated. I had a purpuric Vbeam about 3 months ago that was a disaster. It left me very hyperpigmented and a significant increase in redness/flushing. Prior to this laser treatment, I never had to consider medications to control the flushing. Now I am on: 30 mg of Remeron nightly, and 10 mcg of Propanolol. I found that this combination reduced my flushing by about 70% - so a big improvement. I already have a relatively low blood pressure (100/60) - and the propanolol did not negatively affect my blood pressure. I noticed that it helps dramatically with social/anxiety flushing. However, I am still struggling with warm flushes - so entering a warm room, artificial lighting, computers, AND SLEEPING!!!! Is it possible/safe to add clonidine to my medicine cocktail? Can it be safely used in combination with Remeron and Propanolol? What dose do you recommend? I am worried about "rebound" flushing and potentially making the flushing worse. One final question - is there hope that my pre-laser treatment flushing response and baseline redness will return after some time? It's already been 3 months with no luck so far... Thanks!! Yo

Dr Peter Crouch (↑Disclaimer):Hello flushingmad, Thank you for your question. I can't really advise you specifically on recommended medicines because I don't have access to your medical records and I specialise in IPL/lasers (you would be best asking your physician about what would be advisable for you). You may return to your pre-laser treatment baseline given time but unfortunately there are no guarantees.

Claude

Dear Dr Crouch First, thank you so much for taking the time to do this Q&A! I had two non purpuric Vbeam treatments last spring. It seemed to have help for confort during the summer (less flushing despite hot weather and less burning during the flush episodes) and a little bit for redness. But the redness came back this fall and the flushing too. In fact, I feel that I flushed more easily now than before the treatments (is that possible?). The flush are also different now. I don't have those burnings I had before the treatments but I still become very red and my girlfriend noticed that this redness is wider now. Before treatments, it was mostly the upper cheeks that were becoming red. Now, it's all the cheeks (which correspond to the areas where I had the laser treatments). I told that to my derm but he said that It was just because it came back and that I need one or two other treatments to maintain the results of the two first treatments. Is it possible that the Vbeam treatments increase the flushings or accelerate the progression of my rosacea? My treatments were very light (no bruising, a little bit swollen for 1-2 days, etc...)? Thanks again and Merry Christmas! Claude

Dr Peter Crouch (↑Disclaimer):Hello Claude, Thank you for your question. It is possible that your condition has progressed since your treatment. I think your dermatologist may well be right and that you need more treatments to maintain the initial progress. I would seek their advice and bear in mind that they might suggest a different treatment now that the situation has changed. You might need to consider Intense Pulsed Light if the emerging redness is now more problematic than the flushing now.

ajb.23

Dr Crouch Thankyou for taking time to answer our questions, very appreciated. I have suffered with terrible, constant flushing for about 36 months now. I was diagnosed with rosacea last July and since then have been prescribed about 6 different topical/oral treatments...none of which made any difference whatsoever. My GP is extremely reluctant to refer me to a dermatologist despite my persistant requests to see one, so I am now considering coming to the Burghley Park Clinic for IPL treatment. My question is is IPL an effective method of long term flushing correcting? I also have a question regarding skin after the treatment..assuming the flushing is successfully treated, will my skin tone revert to 'normal' ? Or will the area that has been flushed for years seem a different texture/shade to my 'unaffected' skin? Also I have tried many times to register an appointment on your site lately and filled in the form but never seem to get a response..Im wondering why? Thanks

Dr Peter Crouch (↑Disclaimer):Hello ajb.23, thank you for your question. Normally I would recommend Nd:YAG laser for flushing rather than IPL. Over time, the affected skin may normalise when no longer flushing as much. I'm sorry if you have had trouble registering, all of our bookings have been completed online now for nearly 12 months and the feedback has been very positive so I would recommend that you persevere and attempt to re-register. Some patients have found that our emails have turned up in their spam filters (worth checking if nothing comes through). We have just reviewed the last 200 bookings and they seem to have proceeded fairly flawlessly so the initial kinks inevitable in any new system seemed to be ironed out now.

Snegovik

Low dose accutane and laser treatment I had 2 Vbeam perfecta treatments while on low (2-4mg a day) dose accutane and 2 leg surgeries (plantar approach to remove a nerve) 3-4 weeks after ending the accutane course. My dermatologist said he would not use Co2 laser while on accutane, but Vbeam perfecta was okey on such a low dose. My surgent said the healing of my leg went fine, and faster than most patients. He said he would worry more if I was a smoker, than on a mini dose of accutane that I stopped 3-4 weeks before the surgery. May I ask your opinion about this? He is also careful when patients take a full acne dose, and with some lasers. I had no problem at all with my healing while on accutane. In fact I had more problems with the treatments I had when I was off it, because my skin became very oily and red a week or so after. Thank you for taking time to answer us. Best regards Snegovik

Dr Peter Crouch (↑Disclaimer):Hello Snegovik, Thank you for your question. I am very respectful of the effects of roaccutane on the skin. I think that you have been lucky, some patient's skin, even on low dose roaccutane, becomes very fragile and sensitive and for those who are very sensitive, carbon dioxide laser could be problematic and your laser physician seems to me to be very sensible by being cautious.