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 9 October 2006

Q. What treatment would you recommend for ears?

Personally speaking, I wouldn't have my ears treated. I have rosacea also and I wouldn't let anyone treat my ears. When it is very important for patients to have their ears treated, I do undertake cautious IPL for ears (mainly the lobes) but I would urge extreme caution before using high energy levels. I would be even more cautious about letting anyone use Nd:YAG to treat my ears. If you can find a physician that has used laser and IPL to successfully treat ears of rosacea sufferers with a low incidence of complications then please let us all know on www.rosaceagroup.org

Q. What treatment would you recommend for eyelids?

In my opinion, eyelids should ideally be treated by ophthalmologists or ophthalmic surgeons with experience in laser eye treatments. Special eye-guards that fit under the eyelids are needed to protect the eye and limit the risk of the laser beam or IPL damaging the eye when eyelids are being treated. When treating patients, I don't venture within the orbital margin (the bony ridge around the eye socket). My eyelids are affected only mildly at present but when they get worse I will be seeking out an ophthalmologist with laser/IPL experience for a specialist opinion before undertaking treatment.

Q. What treatment would you recommend for severe flushing?

Generally I use the 1064nm Nd:YAG (Gemini) Laser for flushing. Although I know of no studies that prove this, based on my experience with the patients I have treated, I have come to believe that the 1064nm YAG laser provides the best hope of tackling flushing. Every patient is unique however and advice should always be sought from an experienced laser physician who has had the opportunity to take a full history from and examine the patient before recommending treatment.

Q. What treatment would you recommend for occasional flushing/blushing?

I treat occasional flushing/blushing with alternating Intense Pulsed Light and Nd:YAG Laser. The theory behind this approach is that the IPL treats the blushing and the Nd:YAG tackles flushing. Every patient is unique however and advice should always be sought from an experienced laser physician who has had the opportunity to take a full history from and examine the patient before recommending treatment.

Q. What treatment would you recommend for permanent redness?

I would personally recommend Intense Pulsed Light using an in-house developed blend of three wavelength ranges of intense pulsed light combined with a medication called clarithromycin ~ provided that the patient has skin that is suitable for IPL treatments (and can take Clarithromycin). (For more information about the T.R.I.P.L.C. protocol, see http://www.triplc.info). Patch testing is often advisable/ and for some skin types it is essential. If a patient does not respond to patch testing (or is resistant to increasing doses of Intense Pulsed Light treatments) then I would recommend a trial of treatment with the 585/595nm Pulse Dye Laser (e.g. Nlite / Photogenica V Star / Candela VBeam etc.). It may not be absolutely necessary to cause bruising (purpura) to obtain clearance (see answer to another question below). I find that the results with the pulse dye laser may be less even i.e. less smoothed out when using the laser compared to an Intense Pulsed Light machine. The KTP laser (532nm) can be used for very diffuse redness but you have to use extreme caution with certain skin types as this wavelength can permanently destroy skin pigment. Every patient is unique however and advice should always be sought from an experienced laser physician who has had the opportunity to take a full history from and examine the patient before recommending treatment.

Q. If IPL and YAG fail to decrease redness do you still use Pulse Dye Laser? Is it necessary to have the settings on bruise mode to halt redness?

I do and although it isn't absolutely necessary to bruise using "purpuric" settings, generally more treatments are necessary if purpura (bruising) is not caused by the treatment. (See answer to question below)

Q. What treatment would you recommend for papules and pustules?

I use Intense Pulsed Light for papules and pustules. I find that the Lumenis One Machine we use can clear papules and pustules very rapidly and patients are often surprised how soon their papules and pustules resolve with IPL. Every patient is unique however and advice should always be sought from an experienced laser physician who has had the opportunity to take a full history from and examine the patient before recommending treatment.

Q. What treatment would you recommend to reduce swelling?

Well, this can be tricky because many of the treatments cause a degree of tissue oedema (swelling) as the skin becomes plumped up with tissue fluid immediately after treatment. If a rosacea patient has a "swollen" face, I would consider using Intense Pulsed Light cautiously (after obtaining a full medical history to exclude other causes for the swelling). Every patient is unique however and advice should always be sought from an experienced laser physician who has had the opportunity to take a full history from and examine the patient before recommending treatment.

Q. What treatment would you recommend for reducing burning?

Burning is a common symptom experienced by many people with rosacea and I can identify with this symptom. Intense Pulsed Light or Nd:YAG can be equally effective at reducing this symptom. Sometimes, low dose medication, (to calm down the burning sensation), is worth exploring first (before opting for laser/IPL) as this can be very effective. Every patient is unique however and advice should always be sought from an experienced laser physician who has had the opportunity to take a full history from and examine the patient before recommending treatment.

Q. What treatment would you recommend for early onset of Rhinophyma?

I would generally recommend Intense Pulsed Light for early rhinophyma (depending upon the patient's skin type and medical history). Every patient is unique however and advice should always be sought from an experienced laser physician who has had the opportunity to take a full history from and examine the patient before recommending treatment.

Q. What treatment would you recommend for 'orange peel' skin?

Again, I would generally recommend Intense Pulsed Light depending upon the patient's skin type and medical history. I have used the Nd:YAG and radiofrequency (Thermage) to treat this condition however it is not licensed for this indication. The theory is that gently heating the psilosebaceous unit (the sweat gland) may assist. Every patient is unique however and advice should always be sought from an experienced laser physician who has had the opportunity to take a full history from and examine the patient before recommending treatment.

Q. What treatment would you recommend for patients with perpetually clogged pores? Does IPL help with this at all in the long or short term?

I would recommend Intense Pulsed Light to treat the rosacea first then mild dermabrasion. A professional colleague in the UK, Dr Mervyn Patterson, recognised my rosacea when I attended a workshop he was running and I took his kind advice to seek IPL before considering dermabrasion. The reason for avoiding dermabrasion before IPL is that it can disrupt the fine blood vessels and make quite a mess. I remain grateful to Dr Patterson for his advice (which I think was spot on) and I would like to fully credit him for teaching me that dermabrasion needn't be ruled out provided that it's done gently after successful IPL. Every patient is unique however and advice should always be sought from an experienced laser physician who has had the opportunity to take a full history from and examine the patient before recommending treatment.

Q. Do you recommend IPL for mild cases of Rosacea?

Yes. I think there is little to be gained by waiting for rosacea to progress before treatment. Although some patients are lucky enough to have their rosacea spontaneously disappear, generally rosacea tends to progress after diagnosis and in my view, its always best if possible to tackle it when it emerges. I feel that at an early stage, rosacea is relatively easy to treat and, if caught early and treated assertively, this is the most promising approach to limit/halt progression. Every patient is unique however and advice should always be sought from an experienced laser physician who has had the opportunity to take a full history from and examine the patient before recommending treatment.

Q. Should IPL/laser settings be different for everyone?

No, not necessarily — everyone is different and, woring with their patient, practitioners will discover the optimal treatment setting for each patient based on knowledge of their equipment, the features and severity of the condition, past experience with treatments and how the patient responds to test patching and progresses with initial treatments. Although patients with similar skin types and clinical features may find that their initial treatment settings may be the same, patients usually end up on settings that may be quite different as their treatment course is tailored to reflect their individual progress.

Q. Is treatment different for those who have used long-term steroid ointments?

Oh yes — long term steroid use presents a tough challenge. Whilst some skin seems surprisingly resistant to the ravages of steroid skin preparations, generally skin that has been exposed to high doses of steroids (especially oral steroids) over a long time can be thought of as "thinner and more fragile" ~ just like the skin of people who are many years older. I generally recommend carefully weighing up the risks of treatment compared to not treating and advise all patients with skin affected by steroids that the treatment course is likely to be like "a road that is treacherous and long". I try to focus on trying to revitalise the skin as much as possible before embarking on treatments for the rosacea alone. I tend to gently use Nd:YAG first keeping a watchful eye on the tissue temperature during treatment. I try to space treatments out so that maximum time for recovery is afforded between treatments. Later on when the skin has had some chance to recover then I will recommend adding in gentle IPL. The treatment course is often fraught with a higher risk of burns or blisters and treatment usually takes a lot longer to achieve results. This requires patience and understanding by both patient and physician. Every patient is unique however and advice should always be sought from an experienced laser physician who has had the opportunity to take a full history from and examine the patient before recommending treatment.

Q. Is treatment different for those who have sun damage?

Again, with sun damage, revitalisation of the skin is also high on the agenda and (as always) skin "sun smart" advice and emphasis on using high factor sun filters before and after treatments is a high priority. Sun exposed areas are generally more prone to certain types of skin cancers and we have to remain especially vigilant with patients who have been very sun exposed.

Q. Does laser only address broken blood vessels?

Sensible doses of all forms of light energy used tends to stimulate growth of new cells by causing controlled tissue damage. The effects of IPL and laser if often many-fold and researchers are investigating what happens at a thermal (heat), chemical, biological and immunological level.

Q. Which IPL/laser machines do you trust the most?

Well, we have been very lucky to have experience with 17 laser and 3 IPL systems at our clinic. Whilst I have been invited to try out other manufacturer's machines, patently, I haven't been able to try every brand of laser so what I say should in no way be taken to mean that I solely endorse any of the lasers or IPL machines mentioned below. The machines that we have at The Burghley Park Clinic and that our team mainly use for treatment of rosacea are:-

Q. What do you tell a patient that has been unresponsive to IPL/laser? Moreover, what do you tell a patient that has responded negatively to IPL/laser? Can you please explain why laser treatment can be a negative tool for some people, worsening their symptoms?

Everyone is unique and rosacea can be regarded as a truly "wicked" problem i.e. a straightforward prediction of outcome without prior observation is unreliable. Sometimes the only way to approach solving a wicked problem is to try to solve it and observe what happens when you try. In order to produce meaningful data about how a patient will react to treatments likely to suit their condition, we start treatment gently and observe very closely how they progress. In my experience the best predictor of likely future progress is, well, past progress. No physician sets out to do any patient any harm however not everyone's skin responds well to even the noblest attempts to help. Sometimes, even with the most cautious approach based on years of experience, the situation worsens unpredictably. I think that the most important knack is to learn to implicitly trust your clinical instincts when they tell you to stop treatment. More importantly, to know when "not to start a particular treatment" at all. People seeking treatment may (understandably) be at risk of "magical thinking" (where they come to believe that their practitioner or their equipment / technique may somehow have supernatural abilities to treat the untreatable). I know that some patients that I see for initial consults are disappointed when I recommend that I don't think that I have anything that I feel can help them with. Sometimes it is the hardest thing to say, but the kindest in the long run. A patient told me last month that "You know it's a shame that Harry Potter hasn't brought his magic wand with him today". Even the most experienced practitioners, like patients, are after all, only human and the science and its application is by no means perfect.

Q. Do you feel that at some point in time, vessels become 'immune' to laser light? That is, is it possible that over time, laser treatment will not help anymore?

I think that what happens is that sometimes the target i.e. the blood vessels are partly tackled by initial treatments and that future treatments have "less to aim at". There can be a process of diminishing return to the point where energy levels would have to be turned up so high (to affect the target) that the risk of burning or blistering is greatly increased and treatment can go no further.

Q. At what point are you at risk of other complications like skin cancer?

I'm assuming here that the question alludes to a frequent concern amongst patients who regularly ask "can IPL or laser cause skin cancer". I have put this same question to world respected professors of dermatology at medical conferences, and it would appear that they truly don't believe so - not at the wavelengths that are generally used in the laser and IPL cosmetic industry. Please note however, there are some intense light and laser devices (e.g. Relume/BClear/Excimer Lasers) that produce energy output in the ultraviolet spectrum and patients treated with these devices should be carefully counselled before choosing to use these devices as exposure to ultraviolet light could raise the risk of certain types of skin cancers and extra vigilance is required. Every patient is unique however and advice should always be sought from an experienced laser physician who has had the opportunity to take a full history from and examine the patient before recommending treatment.

Q. Are treatments getting more successful with time? In a few years, do you think the success rate will be higher?

Science is developing all the time and we can't predict what will emerge in future. I have already observed an impressive upgrade in the comfort and efficacy of the IPL technology that we use in our clinic compared to the machine we first purchased 3-5 years previously. I remain hopeful that the development of the technology and the protocols we are using may bring hope to many who have previously regarded their rosacea as untreatable.

Q. In the past you've mentioned cartilage collapse as a result of too many laser treatments. I'm very concerned about this as I imagine others are who need to continue 1064nm YAGS for extremely severe flushing. Personally I've had 34txs, ears included. Is this collapse joule specific as in too much energy or a result of cumulative insult? Is there anything those in the position of needing lifetime laser therapy can do to minimize the risk of this terrible side effect? In the event it happens, can it be corrected?

Tricky question. To be honest (and I always try to be) ~ we don't really know. I'm not sure I have mentioned cartilage collapse as much as damage. The reason I urge caution about the ear (particularly the cartilage) is that ears have a different capacity to recover from injury compared to other tissues of the face. I wouldn't wish to do anything to jeopardise the blood supply to the cartilage of the ears and this is why I urge caution.

Q. How does your blood mapping technique help to follow treatment progression?

We have been seeking a means of mapping rosacea and thin that we are a step closer with the dermetrics system which uses a high definition camera and polarised ring flash connected to a sophisticated image recording computer . We can specifically apply filters to the images to show where rosacea is visible on the skin and many patients are able to more easily visualise the extent of their condition using this tool. The software provides a standardised means of comparing before and after treatment images so that progress can be more easily measured and this I think is the real strength of the system.

Q. When seeking out an IPL/laser/Dermatologist/other form of doctor that can help treat Rosacea, what should a patient focus on? Should a doctor know anything in particular? What questions should the prospective patient ask?

Core and case dependant specialist knowledge is essential. Asking "How many patients with a similar condition to mine have you as a practitioner successfully treated with the technology that your propose?" is not an impertinent question in my view. Every patient is unique however and advice should always be sought from an experienced laser physician who has had the opportunity to take a full history from and examine the patient before recommending treatment.

Q. What is your opinion on Rhytec Portrait PSR3? Is this a suitable treatment for Rosaceans?

I have no experience of this "plasma" technology. I would be very cautious about any form of ablative treatment (such as PSR3) until clinical results have been evaluated.

Q. What have your experiences been with the Candela VBeam with DCD (Dynamic Cooling Device). Do you feel candidates must bruise under this operation to receive optimal results? How have the results been as compared to IPL?

I have trialled one and was pleased with the results. The DCD worked well and the treatment was comfortable and the results were satisfactory and comparable to IPL. Bruising was not mandatory to achieve clearance (but more treatments were required without purpura).

Q. Is it a good idea not to have laser treatment in hot summer months, so that it may keep flushing to a minimum post treatment?

We have patients travelling to our clinic from all over all year round (many from abroad) and many are concerned for just this reason. To be honest, we haven't noticed that this actually is a major issue or reason to avoid treatments in the hotter months ~ many get around this by travelling in air conditioned vehicles / on air conditioned planes.

Q. What is the best remedy if one has extreme swelling post laser?

Cool the tissues, seek professional experienced medical advice immediately.

Q. How safe is IPL?

Intense pulsed light is not a risk free treatment (few treatments I can think of are completely risk free). It is important to recognise that we don't live in a risk free world. Sometimes doing nothing is not a risk free alternative either. We all run risks every day many of which we don't formally recognise or tend to think about overly much. What responsible IPL practitioners should warn you about are the things that are likely, or moderately likely/expected to happen in the normal course of a treatment. They should also make you aware of the risk of things that could go wrong ~ particularly if the impact of something going wrong is very high (no matter how unlikely it is to happen). IPL by its very nature involves applying intense light energy to the skin and in order to reach proper treatment levels, the practitioner may need to approach energy levels that could burn and/or blister so this is always possible. Even in the most experienced hands burns and blisters can occur. What you really should be able to depend upon is that your practitioner has the experience to ensure that the chance of things going wrong is minimised (not normally ever totally extinguished). You should expect to be made aware beforehand that side effects might happen (so that you are not totally surprised if they do). You should also expect to be provided with an aftercare service that assists you (and competently manages any side effects to minimise any inconvenience caused) if they do occur.

Q. Please can you give your thoughts on test patching before undertaking IPL and laser - what should people expect, what area should be treated etc - or do you believe that it is not necessary?

Test patching can be a very valuable way to check out whether a patient is likely to respond well to a particular treatment. (Some skin types are far less likely to experience problems and probably don't need test patching)

Q. Can removing beard hair by IPL be done during the treatment of Rosacea? Is it completely safe to have the beard removed by IPL for a Rosacean?

Hair loss can be an undesirable side effect, so we warn all patients, (especially men), receiving IPL that this can happen) When hair loss is a desirable side effect of treatment, hairair can be safely removed during IPL treatment

Q. Is there is any difference in the Rosacea treatments offered at The Burghley Park Clinic and The Great Western Laser Unit? Do I need a referral from a GP for both of these places?

No difference in terms of treatment except that The Great Western Laser Unit is set up to provide National Health Service commissioned treatments i.e. does not undertake cosmetic work. I lobby on behalf of those with Rosacea to lobby for Rosacea to be wholly recognised as a medical NOT a cosmetic condition. General Practitioners may only refer to The Great Western Laser Unit (on the N.H.S.) if they have prior authorisation for funding of a treatment course from their Primary Care Trust in the UK. Sadly still, very few,(not all), P.C.T's and GPs recognise rosacea for what it is rather than what it may be expedient to do so on funding grounds and rosacea does not always rate high enough in my opinion (on competing funding priority grounds) to be funded.

Q. How do you feel about a multi-pronged approach to Rosacea?

I am generally supportive — it's often a sensible combination or "blend" of approaches that can be the recipe for success. Many patients ask me if I can recommend cream "X" or combination "Y" but I have to be polite and explain that I don't necessarily have any meaningful experience to share when considering what can be a dazzling array of potential combinations. Patients react differently to each approach and it becomes impossible to predict what will happen when multiple treatments are combined ~ particularly if things don't turn out as expected because you cant always tell which (none, some or all) of the combined approaches is the culprit. I tend to stick to what I know (laser medicine) and respectfully leave "the science of the creams" to others better placed to pronounce based on long experience and research in their own field of expertise.

Q. Since your last Rosacea Forum Q&A, roughly a year ago, has anything arisen in terms of treatments, protocols or new technologies (laser or other) that has caught your eye for potentially effective treatments or that may allow a greater level of treatment success for Rosaceans?

Physicians around the world continue to develop and share their approaches and protocols. I have just (this last week) trialled a laser that is a combination of a pulse dye laser and an Nd:YAG. The first two patients were treated on Wednesday – one patient opted for a split face (half conventional / half new treatment) approach. Both of these lasers have been around for some time so the treatmen. It's too early to say how their treatment will progress but the initial results are promising. The theory behind this approach it to use the 585nm pulse dye laser to deoxygenate the blood for a few seconds shortly before a second laser pulse (this time the 1064nm Nd:YAG) is fired at the same area through the same handpiece. (For the strategically minded /technically interested, this approach is analogous to "painting the target" with one laser to help the second burst of laser energy to find its mark). It is hoped that by pulsing one laser shortly before the other that lower energy levels can be used because and we hope that this will contribute to less purpura (bruising) when treating redness and flushing with the pulse dye laser/Nd:YAG combination.

Q. Does T.R.I.P.L.C. protocol help with hormonal acne rosacea?

IPL can help with most cases of rosacea and provided that the patient has skin that is suitable for IPL treatments (and can take Clarithromycin), TRIPLC may be suitable. Every patient is unique however and advice should always be sought from an experienced laser physician who has had the opportunity to take a full history from and examine the patient before recommending treatment.

Followup questions 17 September 2006

Q. Regarding IPL settings listed on http://triplc.info ("Typical Treatment Parameters"): Assuming patient responds fine to energy levels mentioned (20 to 24 J/cm2) in first treatment - do you usually go higher in subsequent sessions? If so - what steps do you make with each treatment and what would be a typical limit that should not be exceeded?

Thank you for the question — I am always cautious with any new patient especially if there has been no previous exposure to Intense Pulsed Light. Provided that the initial treatment has shown no signs of danger (i.e. any treatment associated redness settles down immediately) and (hopefully) some sign of improvement e.g. reduction in flushing or baseline redness, then I would discuss increasing the fluence (power) settings on subsequent treatments. The important thing to bear in mind is that some improvement at each treatment with no side effects is a worthy goal. The temptation is to increase the fluence constantly on subsequent treatments but this may just lead to a fluence that causes side effects. Generally, I think that this temptation should be resisted and this is what I advocate — provided the general trend is steady improvement then it is often best to remain improving and not risk side effects.

Q. Is there anything that can be done/taken to reduce bruising If there are no safe drugs at all - would stopping drinking water some time before treatment thicken blood and cause less bruising?

Thank you for the question - Combining treatments may reduce bruising e.g. Nd:Yag and Pulse Dye on sub-purpuric (= no bruising) settings. I wouldn't recommend restricting fluids (this won't actually significantly "thicken" the blood).

Q. Can applying treatment head with too much pressure on skin result in less efficient treatments? In addition to above concern - is it better to wait until device has recharged (which can take some seconds) before applying head to skin?

Thank you for the question - Some very fine vessels can be "blanched" by heavy pressure so a light touch may be required. For those machines which use contact cooling (like the Lumenis One) then contact is necessary in order to cool (and therefore help protect) the epidermis of the skin.

Q. I wondered how Dr Crouch feels about treating people with Rosacea and other conditions such atopic dermititis or seb derm. I actually have all 3 and IPL makes them flare up pretty bad. Is there any hope of new machines that could help seb derm as well for example? Or, does he use a different approach for these people?

Thank you for the question - When Seb Derm is present then IPL can cause a flare and patients should be prepared to have one condition flare up whilst the other is being treated. Hopefully, this will be a temporary flare and, once this has settled, the other condition i.e. the Rosacea may be better controlled as a direct result of the IPL treatment. If a patient is prepared to accept that one condition may get worse for a short while in order to treat the other then IPL can still represent a viable treatment option for a mixed seb-derm/rosacea picture.


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