Dr Peter Crouch MB.BS.(T)GP. Section 12 Approved
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.
Mattdog323: Hi Dr Crouch, I had a bad experience with ipl in 2007, I received 6 treatments, At the time i didn't now wiser and got sun burnt badly after two sessions of ipl, Ive developed a very rough skin texture as a result, Currently I'm trying higher filters on the lumenis one to produce more collagen and try to smoothen my skin, My texture is very keritosis pilaris like, How do u go about treating rough texture? Have u ever seen ipl mishaps which give a huge texture change? Does it come down to a chemical reaction? Is producing collagen the key? Is the 695 filter capable off doing this? Thank you very much, Matt
Dr Peter Crouch (↑Disclaimer): Dear Matt, Thank you for your question – sorry to hear you had a previous bad experience with IPL. Texture change is something that I warn all patients about as a possibility however I haven’t seen this with patients I have treated using three passes with the Lumenis One IPL at our clinic (we have just completed our 20,000th treatment shot over 5 years).Texture change has however been reported by at one patient who has had much "hotter" treatments previously elsewhere and the risk of this happening could be related to the higher fluences used with single "hotter" treatment techniques. Texture change in my experience therefore seems to be thankfully rare and I assume is possibly protocol and/or technique dependent. Certainly IPL may help however I would steer away from the filters, fluences and therefore wavelengths which caused the texture change in the first place (and head more towards test patches aiming to stimulate photorejuvenation with 695 rather than go below 590nm). I hope that this helps, Kind regards, Peter
Phlika29: Dr Crouch - Many thanks for helping us out with another Q&A. Has there been any new developments in the use of lasers for rosacea over the last year or so? any new products that are in the pipeline?
Dr Peter Crouch (↑Disclaimer): Dear Phlika, Thank you for your question – I'm always on the lookout for new products however having attended several large conferences this year, there appears to be nothing new on the horizon in terms of technology development and I'm not aware of new products in the pipeline. I have nothing new currently on my "Christmas present list" for this year. I think that the current technology base is pretty stable and with the current economic climate, I guess that many of the manufacturers will choose to wait to release new products until after the market picks up again. I hope that this helps, Kind regards, Peter
Melissa W: Hi Dr Crouch, Thanks so much for taking the time to help the RF with another Q and A. Is there any laser/IPL or any other treatment you would recommend for the enlarged pores that seem to be associated with ongoing rosacea? I used to have invisible looking pores and now I definitely notice them on my cheeks. Though I know these can change as we get older I am guessing this has to do with my rosacea since it seemed to happen overnight. Thanks very much and I hope all is going well with you and your family.. Best wishes, Melissa
Dr Peter Crouch (↑Disclaimer): Dear Melissa, Thank you for your question (and for your best wishes). Pore size can be influenced by almost any treatment which causes controlled heating of the sebaceous glands in the skin and IPL or laser or radiofrequency can help to shrink pore size. I hope that this helps, Kind regards, Peter
WrinkledClue: Hi Dr. Crouch, Do you prefer IPL or V-Beam to help rosaceans, and why, please? Thank you for your time. -WC
Dr Peter Crouch (↑Disclaimer): Dear WrinkledClue, Thank you for your question. We use both Intense Pulsed Light and Pulse Dye Laser at our clinic to treat a range of conditions including rosacea. I would generally recommend one over the other based on the patient's symptoms and how they have reacted to past treatments and test patches. Generally, for basal redness or papules and pustules, I would recommend IPL first and use non-purpuric (non-bruising) Pulse-Dye Laser to prevent/reduce any flair up in seb derm post IPL treatment. I would hold purpuric (bruising) Pulse-Dye Laser in reserve for any patient who is non-responsive to IPL – partly because, in my experience, the clearance results with IPL are generally "smoother" with IPL (if it works). Lasers tend to have a more definitive step off across the treated/non-treated margins. Some patients who have had PDL are bothered by the reticulated (net like or "cheese-grater") appearance with purpuric PDL. Some patients who have PDL are also bothered by haemosiderin staining after purpuric PDL and IPL can sometimes beusefully used to great effect to smooth or feather-out both of these side effects. I hope that this helps, Kind regards, Peter
Phlika29: In the last year or so we have been seeing more reports of side effects that people have associated with laser/IPL (such as fat loss). Could you perhaps shed any light on this issue-studies, anectodal reports, etc. If you were new to an area and looking for some one to treat your rosacea with laser/IPL how would you go about choosing (would you want them to be medically qualified, etc,etc)? What questions would you ask when you had your initial visit?
Dr Peter Crouch (↑Disclaimer): Dear Phlika, Thank you for your question. There are anecdotal reports of fat loss circulating and this seems to have developed into a significant area of concern. Unintended unexpected changes are something that I warn all patients about as a possibility however (and sorry to repeat my answer to Mattdog above) thankfully I haven’t seen this with patients I have treated using three passes (at moderate fluence) with the Lumenis One IPL at our clinic. We have just completed our 20,000th treatment shot treating literally thousands of patients over a period of over five years and texture change has been reported by only one patient. The patient who has had much "hotter" treatments previously elsewhere and is convinced that this is due to the higher fluences used with single "hotter" treatment techniques. Texture change or volume/fat loss post treatment in my experience seems to be thankfully rare and I assume is possibly protocol and/or technique dependent. I don’t think that the industry yet knows why some patients can receive many tens of treatments often with high fluences and experience no side effects whatsoever and yet others seem to experience problems with one or two treatments. If I was looking for someone to treat my rosacea or if I was referring a relative or close friend then I would look for the following:- 1) The Clinic should be fully registered with the Care Quality Commission (if in the UK). Don’t be afraid to ask (and be somewhat wary if a clinic can't/won't tell you):- 2) How many times before has the practitioner treating the patient treated the condition with this device? Relevant demonstrable experience is the key here 3) What is the incidence of adverse events for the practitioner treating patients with the same condition with the intended device? Honest appreciation and reporting of the true risk is the key here 4) What proportion of patients with similar conditions treated by the practitioner with the device are content with this treatment? Patient experience (not optimistic marketing flannel) is the key here 5) Don’t be taken in by unrealistic treatment outcome claims. Using phrases like "complete cure" or "removal" or "absolutely no downtime" instead of realistic terms like "improvement", "reduction", "fading" or "minimal downtime" should alert prospective patients to optimistic and potentially misleading marketing hype. Clinics that are more cautious about the prospect of good results are in my view more likely to delight rather than disappoint their patients and this cautious optimism is more likely to be born of experience rather than naïve optimism. Remember, if something sounds too good to be true, then it probably is. 6) Avoid paying for or receiving any more treatments than you absolutely need. If you are done after 2 treatments (or getting no-where after 2-3 treatments) then you should be able to disengage without having committed to a series of paid for treatments. I hope that this helps, Kind regards, Peter
Yvette: Hi Dr. Crouch, Thank you for another Q &A session. Your feedback and information is always helpful and appreciated! I wanted to ask you a few questions regarding Accutane. For reference, I was on low dose Accutane two years ago. It worked great within a month on it (super clear and soft skin) and for eight months off. Then out of nowhere, I experienced bad acid reflux and found out I had a gluten sensitivity - my face went mad!! Prior to Accutane, I had mild acne (but persistent) and I have mild-moderate Rosacea. I can take another course, but have been getting IPL for now and it's helped a lot. So, mainly my questions are for those curious about Accutane or for general information. 1) What is your opinion for treating Rosacea, those with papules/pustules/acne with low dose Accutane (ie. if other antibiotics have failed)? 2) Would you recommend low dose Accutane for persistent flushing only, without papules/pustules/acne? *Most of us here feel type I Rosacea is better treated with lasers and not Accutane, however, your input is appreciated for those curious.* 3) What treatment length do you normally recommend for Accutane? 4) Have you ever performed laser on someone who is on very low dose Accutane? Personally, I wouldn't have laser done while on Accutane, however, there are a few folks on very low dose (ie. 5mg two/three times a week) that have had laser done. What are your thoughts. My question personal questions are : 1) I have a few stubborn veins outside my nose and above my lip area that IPL hasn't been able to blanche or clear. My nose and cheeks are lighter pink, but if there is a better treatment that can help more my ears are listening..... One Derm. suggested Vbeam, Diode laser or schlerotherapy and another said VersaPulse laser (he doesn't have Vbeam - just IPL and VersaPulse)? Please tell me about these treatments and which is best. I did have two Vbeam treatments last year before my skin went haywire (acid reflux and gluten allergy) so I couldn't really see the effects since my skin went bad. Nervous to try to get the stubborn veins now as I don't want to undo the "good" that has been done with the IPL treatments. 2) I still get papules or that sandpapery feeling (likely small comedones) on my jawline. I'm on Oracea - it helps a little. I hear jawline breakouts are often hormonal (I'm a gal) and can also be part Rosacea. Sometimes too, I notice a "pinching sensation" and then a papule is born! For reference, IPL treatments has diminished this sensation quite a bit as it did the papules - maybe I had some "extra" aggressive mites in my skin? Anyway, what other recommendations do you have in keeping this area clearer? I'm allergic to sulfa/sulfur and birth control pills aren't an option, unfortunately. Also, any input regarding mites and their correlation with Rosacea and papules? Feel free to share your thoughts - this topic surfaces a lot. Many thanks for your input and expertise!! Sincerely, Yvette
Dr Peter Crouch (↑Disclaimer): Dear Yvette, Thank you for your question. Low dose Roaccutane can be very helpful but I don’t personally prescribe it (I operate as a laser physician and leave the decision to prescribe Roaccutane to the Dermatologists). As a laser physician, I would tend to use lasers/IPL for flushing rather than Roaccutane – the roaccutance seems usually reserved by the dermatologists for the papulo-pustular rosacea. I personally have not performed IPL or laser on someone on Roaccutane (or within 3 months of being on low dose or 6 months on high dose) because current or very recent Roaccutane use can significantly elevate the risk of side effects as the skin can become more "fragile" whilst taking it. I'm sure that some have managed to have treatments whilst on low dose Roaccutane however the standard I would always set myself would be "Would I recommend to a close friend or relative that they should undertake IPL or laser whilst taking Roaccutane (or having recently finished a course)? No, personally, I would not have laser or IPL treatment nor would I recommend it. For stubborn veins, near the nose – I would suggest that treatment with a variable spot size dual wavelength Nd:YAG (we use the Gemini which has both the 1064nm and the 532nm modes). This usually caters for the larger diameter vessels. The beam and wavelength can be dynamically adjusted to suit the size and colour of the vessel. You might want to try a very mild ablative laser (such as the Venus Erbium:YAG 2940nm laser) for smoothing the skin near the jaw-line. We have an Erbium:YAG laser and whilst know about in the USA, very few patients seem to know about it in the UK. It is very popular with our patients and the vaporisation of the rough skin is relatively painless. Non-purpuric PDL can sometimes help if there is any background Seb Derm. I hope that this helps, Kind regards, Peter
Badeliots: Hi Dr. Crouch, thank you for taking the time to again answer our questions. My question concerns post vbeam hyperpigmentation. I had purpuric vbeam 8 weeks ago and when the bruising faded I was left with hyperpigmentation. I have read that this can be a side effect of vbeam and can persist for months. Is there anything I can do to speed up the lightening? (especially since many of the lightening agents are aggressive and would irritate my skin). Will this hyperpigmentation improve on its own in time? Would a different type of laser or IPL help speed this up? thanks so much. Iris
Dr Peter Crouch (↑Disclaimer): Dear Iris, Thank you for your question – it’s a pleasure. Personally, I would not recommend any of the bleaching agents as you say, they can be irritating and post-treatment hyper-pigmentation usually settles quite nicely given six–nine months and I do not think that there is much practically you can do to speed it away any quicker. Pigmentation that lasts longer than that may be due to residual haemosiderin staining (a breakdown product of the haemoglobin) and if you got this then do discuss this with your treating physician and see what they recommend - this can sometimes be nicely removed with gentle Intense Pulsed Light if they also have one at the treatment clinic. I hope that this helps, Kind regards, Peter
Phlika29 : Sorry Dr Crouch I have another question! What do you think of the use of botox for the treatment of flushing?
Dr Peter Crouch (↑Disclaimer): Dear Phlika, Thank you for your question – I am experienced in the administration of botulinum toxin for cosmetic smoothing of fine lines and wrinkles, relaxing muscles and for the treatment of nuisance sweating. I am aware of botulinum toxin's many applications (there are many more) however I don’t personally use botulinin toxin for flushing and I am not personally convinced of the indications for this aspect of the many emerging potential uses for botulinum toxin. I hope that this helps, Kind regards, Peter
Lindas : Dr. Crouch, Thank you so much for taking the time to share your expertise. I have had YAG and two IPL treatments within a year's time. I now have noticble permanent discolored indentations (scarring) on my cheeks and chin, yet I am unable to determine which of the two procedures caused this as I noticed it much later after the treatments. Would you know which of these procedures most likely caused this? And are there any laser treatments that you would recommend to resolve this, as well as to address the permanent redness/large broken blood vessels still on my cheeks and chin.? Although I would love to have you provide any future treatmeants, unfortunately I am unable to travel from the US to your clinic. Can you recommend several colleagues in the US who have your expertise/knowledge with laser surgery for rosacea patients? Lastly, for some reason, I have now become sensitive to every mild cleanser. I was able to use Cetaphil until four months ago, but it now aggravates my skin. I have tried everything - Cetaphil, Eucerin, Toleraine, Cereve, Aveeno, Aquanil, Olay, etc. to name just a few. What have you recommended for patients who seem to be unable to tolerate anything? Thank you again, Linda
Dr Peter Crouch (↑Disclaimer): Dear LindaS, Thank you for your question – it is a pleasure. When you have multiple treatments relatively close together it can be very difficult to know with any certainty which is most likely to have caused any specific issue. IPL tends to cause effects directly beneath the treatment head. Nd:YAG can be more penetrating. Suspecting that treatments have caused issues and proving it with any degree of certainty can be very difficult and the problem associated with recommending any more treatments is that if you can't be entirely sure which caused an issue in the first place then any further treatments inevitably carry a risk of making things worse not better. When faced with this situation before with patients nervous of trying anything new usually having discussed past problems but with a new practitioner, we usually opt for gentle IPL with conservative settings and go very slowly progressing very cautiously and test patching and observing for several weeks/months is undoubtedly the way to proceed if at all. I hope that this helps, Kind regards, Peter
Wobs: Hi Dr Crouch Thank you for your time. I started six months ago with flushing, burning and tingling sensations. This has progressed to intermittent flushing and sensations leaving permanent red mottled cheeks and the start of p&p. My GP has diagnosed rosacea but offered no treatment. My question to you is, what other treatments apart from light/laser would you recommend? In your opinion what do you believe is the course of rosacea (SIBO,dermodex,genetic)? Which would be cheaper, a private referal from my GP to The Great Western Laser Unit or a private appointment at the Burghley Park clinic? Kind regards
Dr Peter Crouch (↑Disclaimer): Dear Wobs, Thank you for your question – it’s a pleasure. I would initially try Metronidazole gel and/or oral antibiotics such as tetracyclines (I know we all groan that this is where most of us started but it can often work for the initial symptoms). I personally use Professor Nick Lowe's Redness Relief Cream and his Sebum Control Cleanser both available from Boots The Chemists (also via their website www.boots.co.uk) – if you type "Lowe" into the Boots search box it will bring up all the Nick Lowe products. Many patients report that low power red light is beneficial and the Rosacea Forum is as good a place as any to start with research into this aspect of potential help in this direction. You might want to read Colin Dahl's booklet on the Warm Room Flush Phenomenon ( PRACTICAL UNDERSTANDING OF ROSACEA :PART 1: HEAT REGULATION AND THE WARM ROOM FLUSH PHENOMENON By Colin Dahl ,Chief Scientist ,Australian Sciences Copyright 2008 via their website http://www.ausci.com/) as this seems to me to talk a lot of sense. As to the cause of rosacea? – the jury is still very much out I'm afraid – I'm happy to say I don’t think we really truly know for certain. As to the cost of treatment – if your GP would like to refer you on the NHS to me at The Great Western Laser Unit he/she is very welcome to however, in my experience, very few Primary care Trusts are prepared to fund laser/IPL treatments and they would be wise to clear it with their PCT first. I hope that this helps, Kind regards, Peter
Grumpy: Hello Dr. Crouch, My main problem are pustules (not even papules, I don't get those). Did you treat such cases and did IPL work for them? Also, do you think RLT would work? I am tired of taking Accutane and antibiotics because they just work while I take them, the symptoms get back in a few weeks after I stop them. Thank you! Andrew
Dr Peter Crouch (↑Disclaimer): Dear Andrew, I would look at IPL if you are getting pustules – it usually works very well for those. RLT may help (it is unlikely to do any harm and well worth a try). I hope that this helps, Kind regards, Peter
GJ: Hey Dr Crouch Thanks for doing this. i) It seems to me a lot of people are excessively anxious about flushing in the days post IPL/ laser (concerns about angiogenesis and whatnot). What are your thoughts on this and what do you currently advise your patients? ii) Some visiting your clinic may have to negotiate Swindon's Magic Roundabout. As a local, how do you suggest they proceed? Cheers Gary
Dr Peter Crouch (↑Disclaimer): Dear Gary, Thanks for your question – always a pleasure. I think that one can get too obsessive about trying to avoid the inevitable and those who have a less distressing journey seem to more readily accept that treatments are likely to stir up symptoms initially and these can take 4-6 weeks to fully settle down. Sometimes you just have to "go with the flow" for a while after treatments and don’t over analyse why flushing often occurs unpredictably for a while after a course of IPL or laser – it does because that’s what it does…. If you add to the normal flushing all the emotional triggers, is it any wonder that those who are more anxious about it at the beginning probably end up having a worse time because of all the emotional triggers just make it worse. Thank you for the opportunity to inject a little dry humour into the proceedings (as I know is your personal specialty reading the forum – don’t ever stop – a bit of light relief goes a long way) Now, about the infamous Magic Roundabout in Swindon – like post treatment flushing – my advice is also to simply go with the flow (oh and the only real advice is not to forget to simply give way to all traffic on your right). Remember it is possible to permanently remain on the magic roundabout forever if you don’t get off its many mini-roundabouts so at some point make a break for one of the many exits. When it was first conceived, elderly "Swindonians" would sit on benches sharing boiled sweets overlooking the magic roundabout sharing boiled sweets just to watch with utter glee as "out-of-town motorists" stumbled upon the magic roundabout and so get swept unsuspecting and terrified into its many lanes exiting as dazed as they were when they first realised that they had hit it. Mind you, it put an otherwise rather non-descript town on the map for something mildly more memorable than its name appearing on one of the drawer fronts of the TV programme "Room 101" next to "Croydon". http://www.bbc.co.uk/wiltshire/content/images/2007/10/22/msn_magic_roundabout_470x350.jpg http://www.armin-grewe.com/holiday/wiltshire/swindon-roundabout.htm http://www.youtube.com/watch?v=kPANKRHL9HU I hope that this helps, Kind regards, Peter
Dovie: Hello Dr. Couch, Thank you for taking the time for some Q&A: I recently had 3 V-beam treatments each 2 weeks apart. My dermatologist assured me that this frequency of treatment is recommended since the blood vessels are weaker. My settings were as follows: 1. 7mm, 6ms, 9 j/cm^2 - moderate swelling, 75% improvement 2. 7mm, 6ms, 9 j/cm^2 - mild swelling, 85% improvement 3. 7mm, 6ms, 10 j/cm^2 - severe swelling, more splotchy and 3 bruises Do you think I was overtreated?
Dr Peter Crouch (↑Disclaimer): Dear Dovie, I don’t use the VBeam so it is difficult for me to comment on individual sessions with a machine I am unfamiliar with and with a patient clearly under the care of someone able to examine your skin and take a full history with etc. None of the fluences seem excessive to me and you were getting a significant improvement (75-85%) at 9J/cm2 though 10J/cm2 seems to be less well tolerated. Personally I would tend to stick to the lower fluences where you are getting improvement and the side effects i.e. the swelling is minimal. I'm sure that if you discuss this with your treating dermatologist they would be happy to adjust the settings so that you got maximal clearance whilst minimising the downtime. I hope that this helps, Kind regards, Peter
Sparrow-legs: Hello Dr. Crouch I have had one nd:YAG and one IPL treatment with you so far for flushing and pinkness in my cheeks, and I am looking forward to more treatments in the near future. I was wondering- what is the optimum spacing of treatments? I am studying and can only afford to come every five months or so.Will this hinder my progress or am I ok to continue coming to you two or three times a year? Thank you very much, sparrow-legs
Dr Peter Crouch (↑Disclaimer): Dear Sparrow-legs, I wouldn’t be at all concerned if you can come for treatment less frequently and although I'm often asked the question in reverse – i.e. how soon can I come for another treatment, I don’t think that you lose anything by allowing the skin to calm down completely in between treatments. Six weeks would be the minimum time I would leave between treatments and it is normal to see most improvement after the first or second treatments i..e. by the third treatment in any given sequence (after all, with the first treatment we are really gauging how your skin does with a naturally cautious "conservative" treatment). I like to think that this paced approach contributes to there being a low level of adverse events. Once we have one or two treatments under our belt so to speak and we know exactly how your skin reacts to our treatment devices, we can safely turn up the power and push for clearance with safety. I would come for treatment only when finances allow and be reassured that you won't be losing anything by spacing them out I hope that this helps, Kind regards, Peter
Mattdog323: hi dr crouch What in your mind is the best treatment which u have seen work for improving and smoothing skin texture, Thanks.
Dr Peter Crouch (↑Disclaimer): Dear Mattdog323, Whilst IPL can be very good for improving the overall look of skin, a very mild ablative laser, such as the Venus Erbium:YAG 2940nm laser) would usually be my choice for smoothing the skin but only after any superficial vessels have been first treated with IPL. For patients without rosacea, mechanical dermabrasion would be a cheaper much more available option however I would not recommend anything but the lightest dermabrasion for a patient with rosacea otherwise the result of moderate dermabrasion may not look good i.e. breaking the superficial vessels could lead to angiogenesis and very raw bloodied appearance to the skin (not a good look really). I hope that this helps, Kind regards, Peter