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. Kind regards, Dr Peter Crouch

Questions and answers 2 January 2009

Phlika29: Have there been any developments in lasers/IPL or the techniques used since the last Q&A in 2006?

Dr Peter Crouch (↑Disclaimer): Dear Phlika29, Thank you for the question. The manufacturers might wish to argue that their latest reincarnation of existing technology represents a major advance but from where I am sitting, I don't think that there have been any significant advances in technology for rosacea since the last Q&A. I hope that the answer helps. Kind regards, Peter.

Phlika29 : Many people seem to be particularly affected by flushing of the nose. What laser do you think might help the most?

Dr Peter Crouch (↑Disclaimer): Dear Phlika29, Thank you for the question. I would generally recommend Nd:YAG Laser first if there is flushing only (no redness when not flushed) or Intense Pulsed Light if there is an element of basal redness. Many patients opt for an alternating Nd:YAG and IPL treatment course and some of the best results I have seen have involved an alternating course. It is always a good idea to have a test patch first. I hope that the answer helps. Kind regards, Peter.

Melissawohl : Hi Dr Crouch. Thanks so much for offering to do this Q and A for us. Are there been any new drugs in development or in the market now for rosacea that you like? Either for flushing/burning or p&p's? Also, where do you stand on the preflushing issue before laser/IPL? Thanks very much.

Dr Peter Crouch (↑Disclaimer): Dear Melissa, Thank you for the question. Laser and IPL is really my area of expertise. I'm not aware of anything that has particularly caught my professional eye since the last Q&A. As a rosacea sufferer myself, I've found much help from Dr Nick Lowe's Redness Relief Correcting Cream http://www.drnicklowe.com/redness-relief-correcting-cream.html but that it the only topical treatment I need at present. There has been little development in terms of antibiotics. Pre-flushing can be a great way to increase the target IF colour is required. It seems logical to me that it would work with IPL but not with Nd:YAG (actually increasing the blood flow prior to Nd:YAG might not help). I hope that the answer helps. Kind regards, Peter.

Melissawohl: Also, if you have flushing of the nose can that be a sign you may develop rhinophyma? That is, what are the pre- rhinophyma signs and symptoms (if there are any).

Dr Peter Crouch (↑Disclaimer): Dear Melissa, Thank you for the question. I'm not aware that there is much evidence that flushing of the nose directly correlates with development of rhinophyma. There is very little generally collected about symptoms rather than signs. I can understand why so many patients with rosacea with redness &/or flushing of the nose would be concerned that rhynophyma will follow. I'm not aware of any pre-rhinophyma signs - I'm sorry to say that many patients wont know that they have it until they are diagnosed with it although some will not realise that they have it e.g. if they didn’t know that they had rosacea before for example. I hope that the answer helps. Kind regards, Peter.

Melissawohl : With each laser/IPL treatment is there an increased risk of side effects? That is, as more and more procedures are done on your face is there any increased risk of compromising the skin and affecting the healing process? Is there a point where it is just too many procedures for one person? I know it will depend on the individual of course and how they react to the procedure but I am asking for a generalisation. Also, as a part 2 of this question, In your experience does a patient reach a point where the laser/IPL has accomplished all it can and they now plateau and further treatments do not help. Again, I know it does depend on the individual but in general do you see this happening? Or in general would you say most people continue to find relief with maintenance laser/IPL(i.e. once or twice a year) once they get their condition under control with a series of treatments. Thanks again, Melissa

Dr Peter Crouch (↑Disclaimer): Dear Melissa, Thank you for the question. The risk should not automatically increase with each treatment - in fact with each treatment their treating physician should know more about how the patient's skin will / is likely to react. Controlled damage is thought to stimulate repair so the skin may become more light tolerant with each treatment and for many patients I see, their skin is more resilient following each treatment. Part 2 of your Question is very insightful - sometimes the treatment has removed so much of the target that it then becomes difficult to selectively target the problem. With treatable conditions that tend to recur sometimes waiting a little while for the target to develop before re-treatment makes sense (both from a practical and financial standpoint). I hope that the answer helps. Kind regards, Peter.

Boyandhisdog: Dr. Crouch, My question regards treating visible vessels that many people have regardless of a diagnosis of rosacea. What platform or modality of treatment do you find gives the most consistently good results in eliminating visible vessels on the nose and cheeks? Have you found that any person is "laser resistant" as has been occasionally mentioned in articles (which somewhat overlaps with the question above)? Yours, Rob

Dr Peter Crouch (↑Disclaimer): Dear Rob, Thank you for the question. For visible vessels, I would generally use a variable diameter beam mixed treatment wavelength laser i.e. Nd:YAG/KTP Laser e.g. Gemini. Some patients have a laser/IPL treatable condition but their skin cannot tolerate the treatment. Others have skin that can tolerate the treatment but their condition is resistant to treatment. Test patching should confirm both the skin tolerance and the treatment resistance of the condition. Sometimes several treatments (e.g. at increasing energy levels) may be inevitable before it is possible to declare someone's condition laser/IPL resistant. I hope that the answer helps. Kind regards, Peter.

Boyandhisdog : Dr. Crouch, As the pulsed dye laser (PDL) is likely the most common laser platform most rosacea sufferers will have access to here in the states at their local derm (the V-beam probably representing 90% of the market), my question is about purpuric treatments. Have you found in your use of the PDL a better end result with sub-purpuric, purpuric, or stacked treatments for a) visible vessels and b) background redness? Secondly, a fear of "making things worse" is a common thread among rosaceans. There have been several anecdotal accounts of damage or specifically "fat loss" with PDL laser treatments although I myself have had great results with purpuric V-beam. It goes without saying that each patient must first do his or her due dilligence to be certain they are utilizing a skilled and trained operator. That said, in your experience, have you ever had anything you would consider permanent damage from a treatment or has anyone been referred to you that has had permanent damage from a therapeutic and correctly performed application of a PDL or IPL? Best, Rob

Dr Peter Crouch (↑Disclaimer): Dear Rob, Thank you for the question. Sub-purpuric can work but normally takes longer (good choice if you cant stand the down time). I prefer not to stack pulse dye pulses for vascular treatments (increased risk of side effects in my experience). Purpuric PDL can give the best results HOWEVER the punched out look may need to be feathered with IPL after the PDL treatment. I hope that the answer helps. Kind regards, Peter.

Dardanelles: I'm about to undergo my first ever IPL treatment later this week and have 2 very short questions. Of the 6 derms I've seen over the last few years, it's only 50/50 on whether my skin issues are rosacea or not. (1) My skin, in addition to being quite red and prone to minor breakouts (whether they're p&p's or acne I'm not sure), is quite shiny and rather oily. Will the IPL worsen oiliness? Will it have any effect on the "shine" one way or the other (my skin is shiny even when "dry"/not-oily, so that's why I mention it separately). (2) On my cheeks, temples, and occasionally forehead, I get "itchy patches" that sometimes come before a small bump. These patches look redder than the rest of my red skin, are a little hotter to the touch and raised, but tend to go away within an hour or so, especially if I cool them down. I've asked derms, and they sort of shrug and don't seem to know what it is, although they've said "it sounds like hives." No one has ever said seb derm, by the way. Is there a chance this sort of thing could be made worse by IPL? Thank you!

Dr Peter Crouch (↑Disclaimer): Dear Dardanelles, Thank you for the question. Any controlled targeted delivery of heat applied to the skin will (generally) reduce oiliness. The "hives" if that’s what they are, may be triggered by any insult - however mild - it is possible that the IPL may trigger it. A test patch is always a sensible first step. I hope that the answer helps. Kind regards, Peter.

Flemmo : Q1. Theoretically speaking, which treatment is most effective against erythema – KTP or IPL? Q2. Many people use fans, cold water and cooling face masks to rapidly reduce a flush. Some people suggest that “forcing” blood vessels shut in this way will only add to the problem in the long run and can result in rebound flushing and increased erythema. Where do you stand on this? Thank you.

Dr Peter Crouch (↑Disclaimer): Dear Flemmo, Thank you for the question. Both can be effective but I would generally first use IPL as the oedema (swelling) is generally less with IPL than with KTP. I understand entirely the drive to cool flushed "burning" skin - however, constant cooling of the skin can mean that as soon as the cool is withdrawn, a rebound flush can result. Similarly, some cold packs can "cold burn" the skin. Some of the refrigerated masks are so cold they hurt. I hope that the answer helps. Kind regards, Peter.

Flemmo: Some people who have had a course (say, 3-5) IPL treatment report a worsening of their flushing and/or facial redness. Others report a further course of treatments brings about a significant improvement of their initial symptoms. If a patient's symtoms do worsen over the initial course of treatments, would you consider it safe to continue further treatments to address the increased flushing/redness?

Dr Peter Crouch (↑Disclaimer): Dear Flemmo, Thank you for the question. I would generally not recommend more treatments if the first few caused a worsening of the condition/symptoms. I would generally advocate a test patch first (this should indicate if things are going to be made worse) and if the situation is being made worse then to switch treatments to one that does no harm. I hope that the answer helps. Kind regards, Peter.

LavenderVA: Q1. I read an article saying Asian’s facial skin structures differently as Causation’s in general, although some Asian could have very fair skin. It is cited from, http://rosacea-support.org/lasers-ip...sian-skin.html From your experience, do you usually adjust the protocols when you treat Asian patients with acne rosacea? If yes, which parameters do you make adjustment to have a optimal outcome on Asian patient? Q2. How efficient is IPL or other laser techniques to treat Papulopustular type of Rosacea? Thanks much, Dr. Crouch! Crystal

Dr Peter Crouch (↑Disclaimer): Dear Crystal, Thank you for the question. Absolutely - Skin Types III,V,V and VI need special consideration as the melanin content is too precious to want to run the risk that it could be destroyed or over stimulated by the treatment. We would look to use lower fluences (energy), longer pulse widths (less likely to damage the melanin) and consider Nd:YAG rather than IPL for some of the treatments (less likely to injure melanin). Papules and Pustules often do well with IPL - for skin types IV,V and VI, the above advice applies. I hope that the answer helps. Kind regards, Peter.

Beedee: Hi Dr. Crouch, I've had 3 IPL treatments done since late August. The first time I had it done, I had minimal swelling which was very manageable. I was then put on methotrexate, between the first and second treatment, for a different medical problem. The next IPL I had, came with a lot of swelling that night, and the next morning it was even worse, and the same thing happened this time. Methotrexate can make one photosensitive, could this be the cause for the extreme swelling? Thanks! Danielle

Dr Peter Crouch (↑Disclaimer): Dear BeeDee, Thank you for the question. I think that, unless the IPL energy or filter settings were changed, the Methotrexate could well be the issue here - it may have made your skin far more sensitive to the IPL. I hope that the answer helps. Kind regards, Peter.

Flemmo: When an undiagnosed patient comes to you, how do you differentiate between keratosis pilaris and Rosacea? I've read that KP can also be treated with lasers/IPL. Do you treat KP and if so, which laser would you use?

Dr Peter Crouch (↑Disclaimer): Dear Flemmo, Thank you for the question. I usually look at the back of the arms for the red skin patches- KP also tends to have a characteristic hue which gets easier to recognise the more patient's you see. Generally the history is also different and with KP it tends to be longstanding and does not evolve over time. KP in my experience is generally very resistant to treatment with lasers or IPL. The test patch will help to establish the treatability of the condition. I hope that the answer helps. Kind regards, Peter.

Dardanelles: One more quick question from me: If you see a patient with topical prescriptions related to rosacea (or anything else, for that matter), what is your advice is general as to using them before & after an IPL treatment? Do you stay off them for a few days post-treatment, or for a longer period? I'd love to ask this question as generally as possible to be of the most use to the most people, but I'm sure mentioning specific topical medications is relevant to the advice given: Personally, I have been prescribed a sodium sulfacetimide/sulfur wash for use twice a day & Finacea for use twice a day. I was only advised to maybe shelve the wash for a couple days post treatment in favor of a more gentle cleanser (like Cetaphil), but otherwise told it wasn't a problem. Thank you.

Dr Peter Crouch (↑Disclaimer): Dear Dardanelles, Thank you for the question. I would generally suggest laying off the preparations for approx 2 days beforehand (this depends upon what they are - certain creams like Retin A - longer). Some creams contain a sun-filter and this can prevent the IPL from reaching the skin. Generally most topical creams can be applied the day after an IPL treatment. I hope that the answer helps. Kind regards, Peter.

?: Hello, 7 weeks ago I had my 3rd IPL and silk peel. I developed a moderate acne breakout with two cysts and some inflamed pimples so 10 days after my 3rd IPL, my dermatologist put me on Solodyn 45 mg for 12 days. I went to see the dr again after 12 days and was pretty much cleared up and back to my usual occasional mild, small, non-inflamed pimples that come and go. I liked how Solodyn made my oily skin much less oily so my dr said I could stay on the Solodyn for 2 - 3 months if I wanted to and then go off of it. The dr used the Vbeam laser on a spot near my nose and 2 small round pressed in circles were left there which were turning light pink and slowly fading. After being on the Solodyn for a couple of weeks though, this area became pigmented and turned brown. I was upset and puzzled as to why this mark went from light pink to brown but after talking to another doctor yesterday I found out that a side effect of Solodyn is hyperpigmentation. Please see these pictures to see how this mark looks. http://www.flawebdeb.com/pictures.html I am going back to a different dr today to have him look at this mark again. I was told that the two small circles are from the laser. My questions: -Will the two small pressed in circles go away on their own in time? -I was on Solodyn for 5 1/2 weeks before stopping today. Is this long enough or NOT long enough for Solodyn to be in my system to cause any problems or long term side effects? -If the Solodyn did cause this mark to become hyperpigmented, will a bleaching cream and time help this fade away? I am fair skinned and have not ever had hyperpigmentation. -Is it ok to use a product like Proactiv or Nucelle on my skin 2 - 3 months after having IPLs and Vbeam laser? I want to go back on an acne system to help my mild acne. Thank you.

Dr Peter Crouch (↑Disclaimer): I think that the areas should be assessed by an experienced laser practitioner before it would be sensible to form an opinion based on the photos alone. Whilst the Minocycline (Solodyn) might cause hyper-pigmentation, it would be generally unlikely to cause surface irregularities i.e. hyper-pigmentation does not normally distort the surface of the skin (just the colour). I would not recommend using a bleaching agent - most would advise leaving this area alone to heal over time. Proactiv or Nucelle should be fine even a few weeks after treatment but it would be best to follow the advice given by the treating practitioner. I hope that the answer helps. Kind regards, Peter.

Boyandhisdog: Dr. Crouch, With a further question about rhynophyma as it has been a hot topic here recently, do you think it is a singular disease unto itself (i.e. having rhynophyma without rosacea whatsoever) or rather is it the culmination of untreated rosacea in your mind? If the latter, do you believe it is possible to prevent or slow it through careful and concientious management of rosacea symptoms? In your opinoin, does the elimination of nasal vessels by either IPL or PDL do anything to prevent development of rhynophyma in the future. I.E. if one has visible vessels now, does removing them help to retard the possible development of rhynophyma? Yours, Rob What do you find to be the single most defining factor in diagnosing rosacea in lieu of common acne, KP, seb derm, or perioral dermatitis? Without the clear presence of blackheads or flushing, how do you best determine if it is adult acne versus rosacea p&p's for example? To your mind, how can an individual best approach their physician and work with them to determine the most correct diagnosis in the common rosacea sufferer's situation where one or more of the above significantly overlap? Rob

Dr Peter Crouch (↑Disclaimer): Dear Rob, Thank you for the question. I suspect that we may one day discover that they are associated conditions and not simply an extension of one condition. By far and away, thankfully, the majority of sufferers of rosacea do not develop rhynophyma. No one really knows if treating the symptoms of rosacea make it less likely to develop rhynophyma. I have several patients who are really keen to keep their rosacea under control, particularly their nose, hopeful that it will make the likelihood of developing rhinophyma. We don’t know that it will make a difference, but no one on active treatment has so far developed rhinophyma. If I felt that a treatment was unnecessary, I would feel ethically bound to advise the patient that there was little or no benefit to be obtained. This one would be in the "almost certainly do no harm" and "possibly do some good" category. The rub will be that we wont know for several years and several patients have remarked that they would prefer to try to do something to reduce their risk of developing rhinophyma (remember most are having treatment for their face as well) so opt to have the nose treated even if they don’t have redness there on the basis that it might help. If I am still doing Q&A's in 20 years time(!), we might have some anecdotal feedback from the treatment group to report. I hope that the answer helps. Kind regards, Peter.

Alba: Dr. Crouch, 1st all of let me say that I have heard great things about you. God I wish I could just take a flight each time and be treated by you. I live in Miami, Florida and till this day haven’t found 1 single doctor that really knows and understands how to treat rosacea. Yesterday I saw the derm who gave me 3 vbeam laser treatments about a year ago with no real improvement. She says now that she is using the Accent Laser (IPL) Blue hand piece devise and she suggested to use this on me next time. Have you heard this laser being used to treat rosacea? I tried looking it up on the internet but it’s mainly used for wrinkles and cellulite. Thank you so much for your help and for being so thoughtful as to answer questions here. By any chance do you know of any good dermatologist here in Miami or Florida? Gratefully, Alba

Dr Peter Crouch (↑Disclaimer): Dear Alba, Thank you for your question. So sorry you haven’t yet found someone that you feel entirely comfortable with. I believe that the Accent is a radiofrequency (bipolar) device which uses radio waves rather than laser light or Intense Pulsed Light. I haven’t heard of this being used to treat Rosacea. We have Radiofrequency devices in our clinic but we tend to use them to tighten and rejuvenate the skin rather than to treat rosacea. There must be many good dermatologists in Miami or Florida but I haven't had the opportunity to meet or work with any. I would recommend seeking out Members (or Fellows) of The American Society for Lasers in Medicine and Surgery (www.aslms.org) or check out the www.skinandhealth.com website for Lumenis One users. The www.rosacea.co.uk site has some positive (and negative) reviews. Personally, I think that finding a treating physician that you feel comfortable with is quite important. The relationship needs to be one of mutual respect and trust - after all, you are trusting the treating physician with your face and you don't want to worry that someone will act recklessly with an area which you already have an issue with. Laser and IPL treatments are not without risk, the key issue here is that I think that if you are progressing down a risky course, you should be warned of the potential risks and be allowed to decide if you wish to run the risk - side effects of treatment should never come as a complete surprise. I hope that the answer helps. Kind regards, Peter.

Ally24: Hello Dr Crouch, I have had a 6course treatment of Energist VPL Intense pulsed light treatment, while my rosacea and flushing havent gone away, I believe without these treatment it would have become a lot worse. My practitioner recommended 10 treatments of Red Light Therapy. What are your thoughts of this? Also what have you heard of the equipment Ellipse intense pulsed light treatment? Some people say this is outdated. Can you also advise us if possible on recommended camoflage foundations or concelers to hide the redness and flushes as a lot of high street products are not compatable with these intense flushes? Just another question if possible picking up from what Alba asked I live in Northern Ireland and unfortunatley cannot afford to travel over to England Can you recommend practitioners in NI? Thanks for taking the time and I wish you a merry Christmas and all the best for the New Year. Ally

Dr Peter Crouch (↑Disclaimer): Dear Ally24, Thank you for your question. Red light therapy using low powered LEDs should represent no harm and may do some good. Infra-Red heating lamps could make the condition worse - please don’t confuse the two. You might want to check out the Low Level Light Therapy section of the forum. I would recommend camouflage make up by The Red Cross. Linda Sy's green tinted camouflage is excellent however I read that Linda has announced that she is retiring http://www.lindasy.com/store/ and her product line may go out of stock for a while which seems a shame as many patients use it very successfully. Veil is another product line which many patients use successfully. Professor Nick Lowe's Redness Relief Cream is also praised by many patients and I have used it myself http://www.drnicklowe.com/redness-relief-correcting-cream.html Like the question above, there must be many good dermatologists in NI but I haven't really had the opportunity to work closely with any to be able to comment. I would recommend checking out the www.skinandhealth.com website for Lumenis One users. The www.rosacea.co.uk site has some useful positive (and negative) reviews. I hope that the answer helps. Kind regards, Peter.

Dardanelles : Perhaps another question, although it's my third, so I understand if you don't have time to get to it! I understand what many say about "flushing," and I do flush sometimes, by which I mean in my definition, I can feel that my face and or ears are very hot in an uncomfortable sort of way. However, well I don't know if a doctor would consider this flushing or not, the skin in my face is hot to the touch for significant portions of every day. I can't "feel" it, by which I mean, I don't feel uncomfortable or overheated, but if I were to touch my skin with my hand it would be very obvious how hot it is. As I mentioned, this happens every day, for significant portions of every day. I have to imagine it's at least partially connected to my red skin. Is this "hot skin" phenomenon treated by IPL? Or is it a sign that IPL might not work, if I can't stop it from happening? I've only had one IPL so far, and each and every day since my skin experiences several bouts of being hot to the touch, and I can't seem to have much of an effect on it. Will this undercut IPL's effectiveness for me as the blood keeps rushing through my face, or will the IPL eventually make some dent in it? I hope that wasn't too confusing!

Dr Peter Crouch (↑Disclaimer): Dear Dardanelles, Thank you for your question. I think that, with your history, I would be keen to exclude an underlying vasculitis (your primary care physician should be able to arrange a blood test to investigate and exclude this) and if this were negative then I would generally test patch you with the Nd:YAG laser next to see if your flushing responded to that. I hope that the answer helps. Kind regards, Peter.

Valby: Hi Dr Crouch. I have some questions about treating rosacea papules after vbeam. Is it normal for vbeam to trigger a breakout of papules? Is it ok to use a mild OTC hydrocortizone on them for a limited time? If a patient cannot tolerate antibiotics (possible porphyria or pancreatic attacks) how should they treat papules?

Dr Peter Crouch (↑Disclaimer): Dear Valby, Thank you for your question. Yes, pulse dye laser can lead to a papule and pustule breakout after treatment. Normally this occurs 10-14 days post treatment (but this can vary). This is not to be considered a wholly negative event as often the skin is left likely to develop papules and pustules for 3-6 months after a treatment. I hope that the answer helps. Kind regards, Peter.

Man_from_mars: Dr. Crouch Would like to get your opinion on "veinwave" for treating telengiectasias. Thank you

Dr Peter Crouch (↑Disclaimer): Dear Man from Mars, Thank you for your question. I have to say that I see a lot of patients who have tried Veinwave for rosacea and have come seeking treatment as the Veinwave hasn't worked. The manufacturer's of Veinwave might have a vested interest in talking up the system for rosacea but we have Veinwave and IPL and laser in our clinic and our Veinwave machine doesn’t get much use because we tend to use the Gemini Laser/Lumenis IPL for thread veins and telangectasia. There are a few cases where IPL/Laser cant be used but these are rare. Veinwave can be attractive because it is cheaper and, unlike laser and IPL in the UK, does not necessarily need Healthcare Commission accreditation and registration to operate it. Certainly, I would advise all of our patients who opt for it having read glowing reports in the press to downgrade their expectations somewhat. Those patients who have had a test patch on one cheek with Veinwave and on the other with IPL usually express relative disappointment with Veinwave and opt for the IPL at the full treatment session. I hope that the answer helps. Kind regards, Peter.

Ally24: Dr Crouch I have completed a course of 6 IPL treatments and the last 2 were quite effective. my last treatment was on the last week of november and I wont be starting another course till January 2009. For a start do you think this is too long a gap before starting treatments? My practitioner has recommended I try a course of 10 Red Light Therapy (2 treatments a week) My question is would people with mild rosacea see much of a difference after the 10 treatments 2X a week? what sort of difference should one expect to see afterwards? and if one doesnt do u think it is worth pursuing or to go back to the IPL? Also with regards to a previous question about camoflage creams etc there is a company in County Durham "Thomas Blake Cosmetic Creams Ltd who sell camoflage creams etc called "Veil" have you heard of this and what are your thoughts of such products in hiding a flushed face. Do u recommed other face creams or cleansers to use that will reduce redness/flushing? I use Dr Nick Redness Relief Cream. The reason I ask is that being able to hide it through makeup/ creams etc is a major confidence boost. Thanks very much. Ally

Dr Peter Crouch (↑Disclaimer): Dear Ally, Thank you for your question. I personally think that a minimum of 4-6 weeks between treatments seems optimal - I have to say that I worry that the condensed protocols may inadvertently stimulate angiogenesis (new blood vessel growth) rather than suppress it. I see just as good results with treatments spaced 6-12 weeks apart. You might want to ask the question about red light in the Low Level Light therapy section of the forum - you probably are not going to see enough of a response to judge until several weeks into the treatment with the red light therapy. The cost of this might be an important factor. I think that if your last 2 IPLS went well it might be prudent to continue with what is working. Veil is a good product as a camouflage technique. Nick Lowe's Redness Relief Cream is good at reducing how red one looks - sometimes this is good to use as well because it can reduce the amount of camouflage needed (and lets the skin breathe) I agree entirely about the comment about looking less red gives you a good confidence boost). I'm a pretty confident person but Nick Lowe's redness relief cream is a valued part of my "lets not let rosacea get me feeling too down" arsenal http://www.drnicklowe.com/redness-relief-correcting-cream.html . I find Nick Lowe's Sebum Control Cleanser is also very good from http://www.drnicklowe.com/sebum-control-cleanser.html I hope that the answer helps. Kind regards, Peter.

WrinkledClue : Hello Dr. Crouch, Thank you for taking the time to answer our questions. Do you find V-Beam or IPL more effective for treating rosacea? What, in your experience, are the advantages and drawbacks of each? Also, if you could only use one filter depth to eradicate the problematic blood vessels in rosacea skin, which one would you choose? Thanks again. -WC

Dr Peter Crouch (↑Disclaimer): Dear WrinkledClue, Thank you for your question. I use generally use Lumenis One IPL first before Pulse Dye Laser (we have an N-lite rather than a V-Beam) at our clinic. The advantages of the IPL is that it is a smoother, more feathered effect with very little downtime. Sub-purpuric (non-bruising) treatments with a pulse dye laser can be effective but normally take longer. Purpuric (bruising) treatments can be both effective and uneven as the step off in energy at the edge of the laser beam is more dramatic than with an IPL. the reason I use three filters and a triple pass with IPL is to try to target vessels at different depths and to provide a treatment which is effective and with little downtime. Traditionally, the highest fluence tolerated with the "widest" filter setting has been used to treat Rosacea. In terms of the first pass, I usually start with 590nm and progress towards 560nm and occasionally 515nm filters. If I had to use just one, it would probably be the 560nm filter. Thankfully, I am not restricted to using one filter or one pass technique and I'm happy to say that the incidence of side effects (blistering or burning) or downtime (swelling or oedema) is virtually nil using our TRIPLC protocol. I know what I would prefer when I'm treated (more gentle passes and no downtime with minimal side effects) and I think that patients should expect no less that I would choose if treating myself or a close friend or relative. By being gentle and targeting multiple vessels at different depths in a sequence of passes a few minutes apart, I hope that good clearance will result and patients can return to normal daily activities as soon as possible. I hope that the answer helps. Kind regards, Peter.

J-Mill: Rosacea and underlying skin condition Dr. Crouch, Thank you for taking your valuable time to answer these questions. My questions revolves around IPL or PDL therapy for Rosacea where there is an underlying seb derm skin condition. Most practitioners suggest getting the seb derm under control before pursuing laser therapy for Rosacea but for some people this appears to be impossible (there are a number of people on this board alone with recalcitrant seemingly treatment resistant seb derm). I have 3 questions based on this: 1. Presuming the seb derm is not being controlled well through conventional therapies is laser treatment for Rosacea still a viable option? If so which one is laeast likely to worsen the seb derm? 2. Can the seb derm itself be amerliorated at all with laser therapy, if so which one? 3. Can treating the Rosacea component of the skin condition in your experience make hard to control seb derm easier to control? Thank you again.

Dr Peter Crouch (↑Disclaimer): Dear J-Mill, Thank you for your question. We treat Seb derm with Pulse Dye Laser as otherwise the IPL is likely to cause the seb derm to flare up. (This is the complicated bit so bear with me). The PDL effects seem to work for the next time we treat i.e. if we treat on the first occasion with IPL AND PDL then the patient is likely to get a flare up of their seb derm because the protective effects of the PDL don’t kick in immediately whereas the effects of the IPL on the seb derm do. The "NLite chaser" refers to a PDL treatment (with the NLite Laser) that we tack onto the IPL treatment at The Burghley Park Clinic - this provides protection against an IPL induced flare up of the Seb Derm on the next treatment. So an IPL treatment will have IPL followed by PDL. On the last of a series of treatments, there is no need to follow the IPL with a PDL treatment as the Seb Derm flare up is being protected against by the previous treatment's PDL. I do hope no one is more confused after that explanation than before. I think I may have to create a diagram and put it on the TRIPLC website to make it all clearer. If I was to choose a laser to help with Seb Derm alone it would be the pulse dye laser on sub-purpuric (non-bruising) settings. When Seb Derm and Rosacea co-exist, it can make treating the rosacea trickier (it was until we discovered the effects of the PDL chaser treatment). Certainly those patients with both conditions (and I think that this may be very commonly the case that a patient has both conditions present at the same time) seem to do very well with both IPL and PDL when treated together at the same time. I hope that the answer helps. Kind regards, Peter.

PJ: Hello Dr Crouch, I have had several IPL treatments which have resulted in a good improvement of my flushing symptoms. I still have spots on my cheeks that appear to be concentrated clusters of vessels just beneath the skin. After IPL, these spots get darker and appear to coagulate but never do. They often turn into papules after a flush or if somthing irritates my face. Is there any treatment technique or modality that may help with this? Thanks.

Dr Peter Crouch (↑Disclaimer): I wonder if Nd:YAG laser to these areas might be beneficial (it is difficult to advise without examining them) - one always has to be careful that you don’t collapse larger calibre vessels and cause surface irregularities or indentations when the vessel goes. I also wonder what filter settings have been used or how many passes. I hope that the answer helps. Kind regards, Peter.

Grace: Dr. Crouch, Thank you so much for this opportunity. I have a question regarding swelling post IPL. I had my first IPL treatment about 10 months ago and it was pretty aggressive - lots of swelling and some bruising and one small blister. It took months to heal. However I still have some swelling that never completely healed. I'm concerned now that it may be permanent. Have you ever experienced this in any of your patients? I have a pretty severe case of rosacea with lots of flushing, so I'm wondering if the flushing may be preventing the swelling from healing completely. Does that make sense? Could you recommend anything? I was thinking of getting a prescription of diciofenac to see if that may help. Any advice would be appreciated. Thank you - you are a kind soul. Grace

Dr Peter Crouch (↑Disclaimer): Dear Grace, Thank you for your question. I think that 10 months seems a long time for swelling not to go down and I've never experienced that with any of our patients. Any swelling with the Lumenis One IPL is very uncommon indeed (most patients seem pleasantly surprised by this until they have had several treatments with good results and with no swelling involved). I would be surprised if your rosacea was preventing the swelling from going down. Have you been back to you original practitioner and asked for their opinion? I would be reluctant to recommend medication without full knowledge of your medical history and any other/past medication but a trial of an anti-inflammatory sounds like something useful you may wish to discuss with your primary care physician. I hope that the answer helps. Kind regards, Peter.

Pretty_boy: Hi Dr Crouch, I have had steroid induced erythema and facial flushing for 4 months and is progressively worsening, I had 1st ipl treatment yesterday with lumenis quantum with what i would call a less experienced operator(as I have no other choice where i live) whos protocol is usually just a single pass with 560nm filter or 590nm. I have studied for a year before getting ipl so i asked her to focus with deeper filters for the flushing namely the 755nm(not on beard area), the 695nm and the 640nm to target feeder vessels. My question to you is what pulse width and pulse delay time would YOU personally use regarding these filters. To my belief the smaller superficial and shunt vessels require shorter pulses and minimal delay around 10msec delay and the deep feeder vessels(which i specifically want to treat more) require longer pulses with longer delay time.I have also read about the short pulse/long pulse theory. So I would just like to get your professional answer to the above question, and lastly what fluence range do you think would be duplicating the effect of the lumenis one because i merely understand that if you use 24joules with the lum 1 then with the quantum you need to be up around 36joules to get the same effect. Thank-you for giving forum members a chance to get your professional oppinion. Kind Regards Benji.

Dr Peter Crouch (↑Disclaimer): Dear Benji, Thank you for your question. Personally I start with pulse widths of 3milliseconds with a delay of 30msec followed by a second pulse of 5milliseconds followed by another delay of 30milliseconds then finally a 5 millisecond pulse. The translation of joules between the Lumenis One and the Quantum is not a straightforward multiplication. When the Lumenis One came out, we were the first clinic in Europe to use the device and the advice was not to expect to use the same settings as the Quantum - approx 2/3rds of the Quantum fluence was considered to be roughly equivalent. When we developed the TRIPLC protocols, some have tried to calculate what the equivalent would be using the Quantum and I have to say, I don’t think they can be directly correlated like this as, although they are from the same manufacturer using IPL, they are different machines. The Lumenis One is a more sophisticated platform. At The Burghley Park Clinic we have used the Quantum, the Vasculight and the Lumenis One however, I would not choose to use the Quantum to treat rosacea any more, not that we now have the Lumenis One. The main improvement is with the cooling and the need to use comparatively lower fluences to get the same effects. I cannot personally see the advantage of a single high fluence pass straight out of the gates until you know that the patient's skin can tolerate it. We have lots of patients returning for treatments using the TRIPL technique and have a virtually nil side effect rate. The Quantum CAN successfully treat rosacea and there are some very experienced practitioners around with Quantum machines. The experience and approach adopted by the operator is as important in my view as the platform used. I hope that the answer helps. Kind regards, Peter.

Pretty_boy: Hi again Dr Crouch, This question slipped my mind earlier. As I mentioned I had 1st ipl treatment and the operator suggested not using the chiller on my passes. Of course i was hesitant but then i was in the same mindset as her, meaning we both thought that because we are wanting to banish flushing, we obviously want the ipl to see as much as it can to target more vessels hopefully so having the chiller off will give maximum heat at lower fluence and keep the face flushed. So i softly wiped my face with a washcloth as that will make me start to flush then we started with the 755 filter and ended with the 640 because i thought that if we start with the higher filter and work our way backwards that it wouldnt create to much overheating and further erythema,as you would know that the lower the filter, the more heat is passed through.( the joules used were only 26 for each pass as the chiller was off)So the question is That there is a fair amount of study that shows using the chiller is more efficacious then having it off. but after my first treatment doing it this way i am noticing results, the flushing is less present and te burning is almost non existant,and there are a lot of people who get treatments havibg had the chiller on and they dont notice any improvement until the 3rd or 4th treatments. So what is your theory behind using a chiller or not. Kind Regards and thanks in advance.Benji

Dr Peter Crouch (↑Disclaimer): Dear Benji, Thank you for your question. I have to say that the chiller on the Lumenis One is usually fairly critical for preserving the safety of the epidermis. I can see why no chiller might work initially BUT beware increased risk of side effects i.e. burning/blisters if the chiller is turned off. With good epidermal cooling, I find I can drive the fluence (energy) much higher and when the filter is narrowed towards 590nm, the ability to use higher fluences means that I believe that we can drive the light deeper without risking the epidermis and hopefully without stimulating angiogenesis (new blood vessel growth). I hope that the answer helps. Kind regards, Peter.

SolomonCox: Thanks Dr Crouch for contributing your time to us. We all appreciate it. What should a successful IPL look like after the treatment? Inflamation, general skin color, pores, telangiectasia color and intensity, etc? Hope all is well.

Dr Peter Crouch (↑Disclaimer): Dear SolomonCox, Thank you for your question. After the treatment there should be limited inflammation - initially - no more than slightly "sun kissed" -almost as if you have been to the beach for the day (wearing sunscreen and a wide brimmed hat of course) and feel the skin slightly tighter than normal but with little or NO swelling. Any blotchiness should settle within a few hours. I find that the 695nm TRIPL settings often send the blood vessels into temporary spasm and patients often look paler immediately after treatment but this eases off after a few hours and is normal and to be expected. Prominent telangectasia may become purple (this usually means they are about to disappear). The following day, no one should really be able to tell that you have had the treatment. After a few weeks, the pores may appear smaller and the area treated may appear paler. At four-six weeks the full effect should be seen. The colour should be more even and the skin should adopt a more milky even coloured appearance. I hope that the answer helps. Kind regards, Peter.


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