2008 Q&A - Interview with Dr Nick Soldo

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Philka29:
Hi Dr. Soldo and many thanks for agreeing to do this Q and A.
Do you ever treat the eyelids and if you do how do you protect the eye?
What treatment would you think best for potential early stage rhinophyma?
If rosacea is mild would you recommend starting laser/ IPL treatment early to avoid progression.
Many thanks
Sarah



Sarah,
I don’t often treat eyelids but if I am going to do it I use numbing drops and insert eye shields.
Early stages of rhynophyma react well to IPL plus oral doxycycline (oracea) and I supplement with Nd:Yag for the entire nose each treatment.
Rosacea can never be too mild to treat. My opinion is that every flushing episode generates some new vessels (angiogenesis) so elimination early is desirable.






Man_from_mars:
Dr. Soldo,
Is there a different method in treating telangiectasias from steroid induced rosacea vs. a treatment to reduce flushing and overall redness?
Are all telangiectasias treated the same?
-circular spots around outer cheeks and sides towards the ears
-lines around the side of nose and nostrils with some diffuse background redness
Thanks for your support,
Man_from_mars



Man_from_ mars,
There is not a different method that I am aware of. I treat all telangectasias with IPL plus KTP and Diode lasers, but of course the settings vary depending on multiple factors as size, location, skin color, etc. Circular spots, lateral cheeks and pre-auricular (in front of the ear) are hard to treat in my opinion-- but again, all vessels (superficial and deep) require some or all of the modalities mentioned.






Francois:
Dr. Soldo,
Thank you for your time.
I know that Lumenis One is your choice of IPL but what do you think about IPL devices such as Scition BBL, Starlux and Limelight?
Is there a major difference between IPL’s manufactured by different brands in terms of the protocols and the device settings that should be used, meaning would you still use the same filters, pulse width, number of passes and other variables with Sciton BBL, Starlux or Limelight?
Francois



Francois,
Let me begin by stating that I have several lasers in my office, and not all are by Lumenis.
Over the years I have used even larger numbers of devices, and to date, the Lumenis One is my first choice for treating the flushing and erythema of rosacea or solar damage. Why?
1. It is the ONLY IPL that allows multiple sequential pulsing, i.e. allowing up to three pulses with one shot, and also allowing the operator to shorten or lengthen both the pulse widths and the pulse delays.
2. It is the ONLY IPL that uses OPT technology, which is the ability to deliver energy evenly throughout each pulse, thus it is safer and more effective on the higher fluences usually needed to treat rosacea.
3. The Lumenis One has multiple depth filters, and can go deeper than other devices.
4. It is the highest powered (2100 watt) IPL on the market, which delivers high peak power and short pulses to better break up the vessels.
5. I can tweak all the parameters independently, and no other device has that unlimited range of variability.






Markjack:
Hi Dr. Soldo,
There are things going around at the moment about IPL and fat loss and skin indentations? Have you ever encountered this before? Is this down to an inexperienced technician or is it case-by-case basis and this potentially might happen to anyone?
Thanks,
Mark



Mark,
As previously mentioned, I have not personally seen any such occurrences. I do admit that anything is possible in medical treatments, but I assume this would be rare.






Spav:
Hi Dr. Soldo,
My question is about energy levels for IPL that you use on your patients. How do you find the optimum level for person?
The reason I ask is during my treatments using a 3-pass protocol (on Lumenis One) have gone from a range 20-24 J for each pass (24 for the longer wavelength) to recently up to a 28 J for them all. I’m told my skin is very light tolerant. However I’m not noticing any improved benefits. Is it a case of maximum energy for maximum coagulation? (without burning of course)
Thanks,
Spav



Spav,
Again, there is no such thing as normal settings. Every patient varies, and every treatment on the same patient can also vary widely. Excessive settings are not necessarily desirable. I am convinced that more gentle treatments are often more beneficial.
I long ago gave up on trying to beat up on the face and its blood vessels. It’s traumatic to the face to use settings that are too hot, and trauma leads to angiogenesis. I find gentle IPL is often more effective than super-hot treatments, which can lead to excessive flushing and burning post-treatment, and traumatize delicate rosacea skin.

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Ally24:
Alkaline diet
Yes it would be very interesting to hear your theory regarding the alkaline diet. I have read online about the advantages of this and that it claims if you stick wit heathing foods that are only alkaline, and drinking green tea, it “cures” rosacea. Do you think the main cause of rosacea is food diet?



Ally,
To date, nothing cures rosacea. I doubt the main cause is dietary. I think people’s nutrition is important, but by itself is not a cure all.






Altria123:
Dr. Soldo,
I have been treated by numerous triple pass lumenis treatment based on your protocol with beard loss. It has been 6 months and my hair growth is still stunted. Is this permanent, if not how long before my beard grows back based on your experience?
Is cleansing once or twice better for rosacea?
How can you get papules when one doesn’t flush in that area?
Can one be immume to anti-inflammatory effect of doxycycline even if he may be immune to the anti-bacterial effect?
-Altria123



Altria123,
Patchy loss of beard is common with IPL. I have personally not seen permanent hair loss with the filters we normally use (560, 590, and 640) at normal fluences. It usually requires deeper filters to attain permanent hair removal. I suspect your beard will yet re-grow given more time.
Cleansing twice is acceptable, providing one uses non-irritating cleansers.
Papules generally occur in the central face, but can occur anywhere, even in a non-flushing zone.
We know any medication can lose its effectiveness over time. I have seen patients who initially get maximum effect with Oracea, but the effects lessen with long- term usage. This is common with many medications, that the effects lessen over time.






Justakid
Dr. Soldo,
Can you compare the redness of rosacea, to the redness of Keratosis Pilaris Rubra Faceii from a laser treatment point of view?
What is your view on micro ETS surgery, worth the risk to stop flushing/blushing?
Which laser do you feel would treat just permanent redness the best, and what power settings do you think would be appropriate?
Thanks
Nick



Nick,
The worst result I ever had was with a teenager with KPR. I eventually referred him to a fellow physician who used a PDL, and even he did not get good results. Everything with KPR can be quite resistant compared to rosacea.
I am simply expressing my opinion here, and I admit that it is more anecdotal than scientific, but I have had a lot of exposure to patients having undergone ETS.
I used to refer some scleroderma patients for ETS (for vasodilatation), and none of them had anything but a temporary result, while many seemed to experience unpleasant psychological problems like depression. Consequently, I have NEVER referred any rosacea patient for this procedure.
Many that I have seen who have undergone ETS have been less than satisfied with their experience long term.
In my opinion, the Lumenis One is still the most effective laser to treat permanent redness. Remember, there are no set power settings for all people-- each patient has to be individually evaluated, and each treatment session will probably also require different settings.






J-Mill:
Dr. Soldo,
My question involves treating rosacea with IPL when there is an overlapping skin condition such as seb derm or eczema. In your experience how frequently does IPL aggravate these overlapping skin conditions and what is your recommendation for these patients.
Thank you for your time,
J-Mill






J-Mill,
I believe that all underlying associated skin conditions need to be under some control prior to undertaking IPL sessions.






Spuggylegs:
Quote: Originally posted by markjack
Markjack
Hi Dr. Soldo,
There are things going around at the moment about IPL and fat loss and skin indentations? Have you ever encountered this before? Is this down to an inexperienced technician or is it case-by-case basis and this potentially might happen to anyone?
Thanks,
Mark
Hello Dr. Soldo
Just to carry on from mark’s question. A lot of literature states that IPL will not harm skin, yet after having a disastrous lumenis 1 session, not only was my rosacea worse but I was left with numerous small open pores where I had had the treatment. Is this common?
Thanks



Spuggylegs,
I am not convinced that a properly conducted IPL with patients who adhere to proper guidelines harms skin or causes damage or fat loss. I personally have not seen fat loss except with the use of RF devices, which is well documented in the literature.






Ally24:
Dr. Soldo
Hi sorry if this is a silly question but what makes a person unresponsive to IPL/laser treatments?
Are there bad side affects i.e burns, scarring, or making rosacea worse?
Can IPL/laser treatments work for everyone, if not what are the alternatives for controlling flushing/blushing?
Would IPL/laser be your next state in treating rosacea after no success with antibiotics?
Thanks for your time






Ally24,
Some patients are slow to respond to IPL, but I believe that if enough IPL’s are performed, if supplemental oral and topicals used, and if the patient is compliant with my guidelines and instructions, then all patients will show improvement. This is obviously variable, but we strive for a minimum of 50% and even up to 80-90% improvement. I do not rely on antibiotics except in subclinical forms (Oracea etc), and IPL is still the only definitive treatment to reduce erythema and flushing.

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Ally24:
Dr. Soldo
Hi may I ask what is your opinion on having an anti yeast diet?
Do you have a diet of this in practice and if so could you post it please?
How do you go about getting tests done to see if rosacea is cause by hormones; harsh topicals; vascular already in origin or fungus- resulting in vascular problems.
I am asking because I have had a fungal infection on my big toes which I still have despite painting lacquer treatment on since 2006. I then had a bad and (unexplained) constant sore throat red and raw from new years day 2007 everyday to September 2007 (I took antihistamines) at this stage I had bouts of thrush and then I got the ear infection in September 2007 which cleared up in January 2008. After that I was diagnosed with rosacea.
Do you think this rosacea has resulted in too much yeast/fungus in my body?
How can this be treated other than diet-ie IPL/laser
Many thanks I am sorry to bombard you with questions



Ally24,
Unfortunately I am not up to speed regarding yeasts and its benefits. I am always anxious to receive information regarding anything that patients tell me works for them. If I suspect a significant hormonal factor with rosacea, I prefer to work in conjunction with their Gyn. physicians to test for and treat with hormones and possibly spironolactone. We have had some degree of success in this regard.
You have asked some very interesting questions and again I am honestly not sure the role of yeasts and fungi. As you know some believe other causative agents include demodex mites, heliobacter pylori, bacteria etc. All studies on all the above unfortunately are quite inconclusive.






Adam_h:
Dr. Soldo,
I have a skin condition in which ‘pore plugs’, which looks like dry bits of skin on the pores and feels like sandpaper to the touch, cover my t-zone area, especially the nose. In order to get rid of them I have to exfoliate every day- I have tried all types of moisturizers and these haven’t been able to get rid of them. Using a cleanser makes my skin very dry and my skin produces even more oil than it already produces. Therefore, I just use a moisturizer and exfoliator. Also, I have rosacea symptom- redness and flushing.
Have you ever heard of this condition before?
Would it be possible that my skin is simply trying to heal itself and by exfoliating the dry bits of skin on the pores, I am not letting it heal? However, the longest time I have left these dry bits of skin on my pores is about 1-2 weeks and they still hadn’t exfoliated naturally.
Any help would be much appreciated.
Thanks,
Adam



Adam,
Obviously no one can diagnose without personal contact with a patient, but one suggestion is to visit a dermatologist to see if this is seborrheic dermatitis, and if so, should be appropriately treated. Then IPL’s can be undertaken to address the erythema and flushing.




Philka29:
On behalf of Emilyancfan:
Is it safe to receive either of these two treatments when you have a slight (but persistent) case of facial edema? Could it possible cause the condition to worsen, and if so, would it eventually return to normal?



Philka29,
It may well depend on the cause of the edema. I have seen mild swelleing of the paranasal and medial cheek areas which I felt were secondary to the inflammatory aspect of rosacea, and have seen improvement post treatment with IPL’s.






Philka29:
From Shamrock
I want to ask the doctor a question-dr. do you think this settings and passes are too high and could cause fat loss in face-it’s a lumenis by vasalight not lumenis one- 1 pass at 560- 1 pass at 590-1 pass at 590-1 pass at 695- and last pass at 755- one of the older photoderm machines 1998 but it was upgraded.
Question number 2- if there was fat loss do you recommend still doing photoderm treatments? Its been 3 years since last one- not worrying about flushing- I have other methods for that- what settings for redness- and some pand ps- thanks jerry



Philka29,
There is no mention of the fluences (power, measured in Joules) used, which could have some impact on results. I might add that 5 years ago I had 480,000 pulses on my Vasculite machine by Lumenis (which means I had used it a lot), and was never made aware of any fat loss. I have seen several cases of fat loss with RF (radio-frequency energy) devices however. I don’t use those machines in treating rosacea.






redKen:
Hi there,
My question concerns blood vessel regrowth and age. I’ve heard that cell activity slows down as part of the aging process. In your time as a laser specialist have you found that older patients have a longer gap between top up treatments compared to those who are considerably younger?
Many thanks for your time.



redKen,
I think that is a very valid comment. I also think this is why some patients have less problem with their rosacea as they get older.

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Downtown:
Hi Dr. Soldo
I recently had 8 IPL’s with the vasculight with no problems, I then went on to have 2 treatments with the quantum both times I reacted with swelling. The swelling subsided but left the bottom halfs of my face somewhat enlarged, like two sort of bulges (they feel jelly like) at the bottom towards the back of my face it also thickens when I eat. Its been over a year now… my question is have you ever heard of IPL causing problems with the lymphatic system, or the systems other than vascular, what happened?
I ‘m 22 have red hair and pale lightly freckled skin. Any help would be greatfully appreciated
thanx
Sam ;)
Ps. I also know of one other case who have experienced this with the quantum



Sam,
I have never used the Quantum, but normally the Vasculite can be far more powerful. I will state again (and again) since it is a very important point that the equipment used is of utmost importance, but possibly not quite as important as the person doing the procedures.

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Philka29:
Would you ever recommend Levulan for people with rosacea?
If you were a rosacea patient and going for IPL/ laser treatment, what questions would you recommend asking the practice?



Philka29,
I sometimes suggest PDT/Levulan in certain patients, especially if they also have actinic keratoses or acne component. Some feel it reduces the number of IPL sessions needed, but I am not totally convinced.
The most important questions are
1. Who will be doing the treatments? Ideally it would be a physician with rosacea knowledge.
2. What is their experience level?
3. What equipment are they using? Some IPL machines are far superior to others. That said, I will modify that by stating that a marginally trained individual can do little good with the best of devices, whereas an experienced, knowledgeable individual can obtain reasonable results with many devices that might not be as modern or superior.






Kristina b:
Dr. Soldo,
Are there any recommendations you would give to IPL patients that could help to reduce post-treatment angiogenesis?
Many thanks,
Kristina



Kristina,
A few suggestions for good IPL results come to mind.
1. I prefer treatments two to three weeks apart. More often, and the skin doesn’t have time to recover; less often, and you get far less benefit.
2. Avoid as many triggers as possible. Easy to say, harder to do, but still a must. Especially avoid heat.
3. Avoid steroid creams on the face.
4. Avoid irritating substances, like acid peels, Retin-A and chemical sun blocks. Physical sun blocks work much better.
5. Do not over cool the face, as cold can also be a trigger.
6. Watch your diet carefully after IPL. Eat mostly fruit (except citrus) and vegetables and fish and whole grains. Avoid highly processed food, fast food, alcohol, caffeine, sugar, and dairy. Avoid acidic dietary substances.
7. Avoid flushing at all costs. I believe that all flushing episodes create new vessels, consequently I long ago stopped pre- flushing prior to IPL.
8. Get some fans and keep them on your face to keep it cool and to shut down flushes ASAP. Your kitchen and desk should have fans on them. I also recommend small hand-held battery powered fans when you’re going out to shut down flushes before they become big.






TheMediumDog:
Dr. Soldo,
What is your preferred means (e.g. IPL, vBeam etc) of going after the deeper capillaries?
Do you experience a significant number of patients whose rosacea is accompanied also by chronically dry skin? If so, why does it occur, in your opinion? (perhaps due to impaired barrier function, lipid production?) Do you find laser/IPL treatment improves the problem?
In general, over what sort of time period do you give patients maintenance IPL treatments (3 months/6 months/a year?) after their initial series of treatments?
What new rosacea treatment(s) are you most excited about, looking to the next few years?
Thanks,
Alex



Alex,
1. Lumenis One IPL with deep filter combined with Nd:Yag give me the best results for deeper vessels.
2. Generally the dry, flaky skin is concomitant seborrheic keratois (about 1/3 of rosacea patients). Often the underlying SK must be treated first. IPL improves the over-all pictures as a result of the increased dermal moisturizing plus healthier collagen.
3. If erythema and flushing are greatly controlled, then and only then I will recommend a once a year maintenance treatment. More severe cases may well need a treatment every 3-6 months, or more often.
4. Recently some exciting research was done in San Diego that showed rosacea patients had higher levels of cathelicidin peptides in affected facial skin compared to unaffected patients. Cathelicidin is known to produce angiogenesis among other skin changes. I suspect methods will be found to control this peptide. It is known that both IPL and PDL lower levels of Cathelicidin.






Gayle:
Dr. Soldo,
Thank you for taking the time to answer and help those of us who suffer from rosacea. I would like to know:
Can the IPL settings be set too high/too aggressive and actually make rosacea worse? Or do you feel that as long as a patient’s skin tolerates the settings without blisters, etc. this is the correct setting.
If a patient has to fly to get to you, how long do you recommend they stay before flying home?
After IPL, how long do you recommend the patient not exercise or take supplements?
Do you have any patients who do not get the desired clearance of symptoms after the ten sessions you recommend? If, so what do you recommend they do next?
Thank you again,
Gayle



Gayle,
Yes, IPL settings can certainly be set too high and too aggressively! I used to believe in cranking up settings as high as would be tolerated. I now believe this is bad and can actually increase angiogenesis, which is blood vessel regrowth. We obviously need to introduce adequate fluence to the skin, but we need to do it in a gentle fashion.
Ideally 24 hours would be desirable for a patient to stay here after IPL, but I do have some patients that travel on that same day without any apparent negative side effects.
I ask patients to avoid exercise and supplements for a minimum of 24 hours after treatment.
And yes, I do have patients who need more than ten IPL sessions. Not all expectations (of doctors or patients) are always met. The vast majority of patients get great results after one or two series of five IPL treatments. Other patients get great results, but they need continued IPL to maintain those results. If the rosacea is particulary advanced, or the patient needs more clearance of symptoms, we do more IPL, plus utilize oral and topical medication. We offer significant price breaks after the first series, so that patients will be encouraged to continue.

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Ally24:
Hi Dr. Soldo,
What treatments IPL/laser would you suggest to someone who has mild to moderate rosacea. Symptoms including flushing and redness which occur only in warm/hot environment, or due to social embarrassment, red bumps and some spider veins? (this seemed to occur after an ear infection which resulted in a red rash like eczema, which is now cleared up).
Do you recommend a combination of Photogenesis using IPL along with Laser Genesis an Nd:YAG laser of 1064 nm for the above to be the most successful and safest option for the early stages of rosacea?
Is it ok to receive these treatments while on Tetralysal (lymecycline)?
Also what do you think of Isolaz PPX Therapy which claims to clear acne but also help clear rosacea?
Many thanks for taking the time to answer our questions,
Ally



Ally,
Flushing and redness respond best to IPL, and I also utilize Oracea and topicals as anti- inflammatories. The spider veins may disappear with IPL, but if not then I use a KTP and/or diode lasers. Occasionally I will even use sclerotherapy on persistent vessels.
I sometimes treat flushing noses with Nd:Yag.
I seldom use clinical doses of antibiotics, so patients do not need to stop them prior to IPL. If they are on therapeutic doses I do not necessarily stop them, but make the patient aware of increased photosensitivity.
I have no experience with Isolaz PPX, but since rosacea and acne are two totally separate entities, I am not sure I see the rationale involved.






Gayle:
Dr. Soldo,
I have a few more questions. In your interview, you stated you have your rosacea patients go on an alkaline diet. Many people recommend a high protein diet similar to Atkins, which I think, is an acidic diet. I know that I personally flush extremely when I eat protein esp. animal protein. Would you please expand on the alkaline theory and perhaps post the diet you put your patients on?
Thanks so much,
Gayle



Gayle,
I can suggest web sites that address diet for rosacea. They include:
http://www.rosacea-ltd-lifestyles.com/
and
www.healthy-skin-guide.com/foods-to-eat-for-rosacea.html
There are also two excellent books I know of,
• “The Clear Skin Diet”, and
• “The Inflammation Syndrome”,
which steer people towards a diet to lessen inflammation. Diet is such an individual thing, and different people respond to different dietary triggers, that it’s really a matter of seeing what works for you.




-Nicholas Soldo, M.D.
Scottsdale, Arizona

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I would like to thank Dr. Soldo on behalf of the Rosacea Forum for helping us and answering all of our questions. We greatly appreciate all the time and energy you spent in helping us here.

Best wishes,
Melissa

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Thanks to Warren here is the Q and A with Dr Soldo in an easier to read format.

http://www.rosaceagroup.org/QandA/Dr_Nicholas_Soldo.php