Yup, sure. Have been pretty busy with moving home. Will attempt to summarise the questions this weekend and e-mail Zenda by Sunday evening.Originally Posted by arb161
Jen
Re: oops wrong place again
Yup, sure. Have been pretty busy with moving home. Will attempt to summarise the questions this weekend and e-mail Zenda by Sunday evening.
Jen
interview
thanks
I need to apologise, as I have not sent the questions off yet. I received a PM tonight and will include that question too. Will be back with a response once I receive it.
Sorry for the delay.
Jen
Questions were e-mailed last night and I received a reply from Zenda:
"Hi, Jenny. I am out of the country on holiday right now so won't be able to get back to you until I return hopefully sometime late next week. So sorry. Just wanted to let you and everyone know so you won't think I'm ignoring your questions.
Good luck on your new home.
Zenda Garcia-Lat, M.D."
Here are the replies to our questions:
Dr. Garcia-Lat,
I and several others have rosacea that effects ears as well as the face. This includes ear flushing in the evening, to heat, and many other triggers. Can you treat these sensitive areas with IPL or do you have any recommendations regarding this? Some of those that have had it done have seen good results, but I know many physicians would rather not treat them due to the sensitivity. Thanks, Ben, Chicago
Hi, Ben. Yes, I treat these areas with IPL as well and have seen good results. However, I also have had patients with ear redness and flushing that I did not specifically treat but whose symptoms abated after I treated their faces with my usual protocol.
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Hi Dr. Garcia-Lat,
Thanks for providing us with this opportunity.
I'd like to know if you would recommend IPL for the flushing/burning aspect of rosacea. Many people have VBeam or Nd-Yag 1064 for that type of roscea. What are your thoughts as to the best treatment for flushing and burning?
Best wishes,
Melissa
Hi, Melissa. I have treated many patients with flushing and burning with IPL. In these cases, I use the deeper filters of the IPL namely, the 695 and 755 and have been quite successful. As a matter of fact, I have patients coming back to me for treatment and long term follow-up (every 6-12 months) who specifically tell me to concentrate on the deeper filters for flushing. These patients are typically not red all the time but they do get extremely red with their triggers and they flush a lot. With the maintenance treatments, they tell me that they don’t flush as much and they can take a drink or so or even do a little gardening and not flush or feel the heat as much. I do not have a V beam so I cannot comment on that. I do have a yag but I do not use this routinely as majority of my patients do very well with the IPL treatments the way I do them. I typically do several passes with each treatment.
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What treatment would you recommend for orange-peel skin and early-stage rhinophyma?
I have not specifically treated patients with orange-peel skin although I have seen a lot of patients whose skin texture improved tremendously with the treatments. As far as early stage rhinophyma, I had only one particular patient who was concerned he had early stage rhinophyma. I treated him with my usual IPL settings and treated the nose with the 1064 yag additionally. He seemed very happy that it did not progress. There were times when he came in just for me to do his nose. However this was just one patient so in all honesty, I cannot make a general comment as to its effectiveness.
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What treatment would you recommend for combination regular acne, Type I rosacea, and seb derm?
Most patients with this combination usually come to me after having been to a regular dermatologist who would have given them some treatment. I usually do my IPL rosacea protocol on these patients and start them on an oral antibiotic like a tetracycline, doxycycline or minocycline if they are not on it already. Many times they already use a mild wash that agrees with them and use some kind of topical cream but not steroids. IPL has helped a lot of my acne patients as well.
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What do you feel is the best way to get rid of telangiectasia?
Thank you.
With telangiectasias, when I treat them with IPL (several passes with different filters) I see them clear up quite a bit. Several treatments may be necessary. When I have very resistant ones, then I target them with the 1064 yag.
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Hi Dr Zenda Garcia-Lat
which treatment do you reccomend to your patients for flushing?
i do not have a permanantly red face,or that many broken veins other than round my nose,i have tryed the quantum IPL which only worsened my flushing...i am scared to try another laser as its left my skin in bad condition...are the other lasers that are not as strong?
thanx alot sam
Hi, Sam. As I mentioned earlier, I have been very successful in treating flushing with IPL using the deeper filters. Of course, I usually start my treatment with a shallower filter to control whatever redness there is and to take care of the superficial vessels. I do this as a first pass. Then I give a second pass using a deeper filter and many times a 3rd pass. I do not see how the IPL worsened your skin or your flushing. I haven’t had that experience.
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Hi Dr. Garcia-Lat,
I was also wondering what you prescribe, if anything, after an IPL or laser treatment. Do you prescribe anything to prevent angiogenesis? Some people use sea cucumber, milk thistle, and/or certain antibiotics (such as clarithromycin that is supposed to help inhibit blood vessel growth).
After a treatment, I tell all my patients to avoid their triggers for about 3-4 days at least. The rationale for this is that with treament, we are closing up the vessels. The way this works is, the laser heats up the blood in the vessels and the walls collapse and close. If a patient's trigger is exercise, for example, the vessels dilate and since they are not yet permanently closed, then they open up. As far as antibiotics are concerned, I do prescribe either a Tetracycline, Doxycycline or Minocycline especially for the ones who still break out and Clarithromycin for those who believe that it inhibits angionesis. And of course, a good sunblock like zinc oxide. Rosacea is a very puzzling disease and different things work for different people. That is why I don't insist on my patients using a particular type of wash or sunblock. I ask them if whatever they are currently using seems to work for them and if it does, then I tell them to stay with it. My philosophy is, if it ain't broke, don't fix it and it has worked for me so far. If patients feel they need something different, then I make them try stuff that works for my other patients. Certain ingredients in these creams and stuff are irritating for some while for others it works very well. But there is not one thing that works for everybody. I also found that in many of my patients, there are a lot of psychological factors involved and stress which also plays a very important part. I find that even just talking to them and spending time with them helps a lot. I do not have any experience with sea cucumber or milk thistle.
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Also, how many treatments would you initially recommend for flushing/burning and what is the prognosis in your opinion for this condition when treated with IPL or laser?
Thanks again,
Melissa
I tell my patients that they need at least 5-6 treatments about a month apart. For some patients, the results may not kick in until after 3 treatments, so patience is the key. I have actually had several patients tell me that for the first 2 treatments, they didn't think it made much difference but they continued with their regular treatments then all of a suddent after their 3rd or 4th treatment they got a dramatic response. On the other hand, I have patients calling me a week or so after the first treatment to thank me for the tremendous difference the treatment has made.
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Hi Dr. Garcia-Lat,
I was also wondering if you pre-flush any of your patients before treatment and what is your thinking on that topic? For rosaceans who go to you for treatment of their flushing do you find you get better results when they are flsuhed before you treat?
Thanks again,
Melissa
There are 2 schools of thought on this subject. Some people think that by pre-flushing the patients before treatment, you get better results because the vessels are there and dilated to begin with. For majority of my patients who are not usually red when they come, I do pre-flush them. Others are of the belief that pre-flushing does not help at all. In my experience, in my patients who are not that red but who do get episodes of flushing, my pre-flushing them before treatment gives them better results.
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Which IPL system do you use. It is my understanding that you use single pass only. Is this the case? If not. Have you considered triple pass to get at different levels of veins?
I use the Lumenis Vasculight which has an several IPL heads and a true laser 1064 ND yag head. I have upgraded a couple of times. It has a "Photoderm" head, an Epilight head and an "SR" head which are all of the IPL technology and a true laser head or a 1064 ND yag. As I have said earlier, I usually do several passes. The only time I may do a single pass is at the very first treatment for a "virgin" case meaning the patient has not had any type of IPL or other laser treatment before and for the patient who is just "red" with no episodes of flushing. The reason for this is, I want to see how their skin reacts to my treatment. If a patient is red and also flushes, even at the very first treatment I invariably do a second pass or even a 3rd pass with the deeper filters to target the deeper vessels.
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Thanks for agreeing to answer some questions for us, it's a big help. My understanding is that you only use IPL for the treatment of rosacea. So i was wondering what you see as the benefits and drawbacks to IPL treatment? Do you have any experince with other laser platforms, like v-beam or KTP? If so for what reasons (results, cost of platforms etc) do you prefer to treat with IPL over these other platforms.
I have been very successful with treating my rosacea patients with IPL
so I haven't tried any other laser platforms like V beam or KTP. I do use the 1064 ND yag head as well in some cases. I have had several patients come to me after having had V beam and KTP and they swear they have had better results with my treatments.
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Also what do you estimate your success rate for treating Rosacea with IPl is?
I can honestly say that I have had over 90% success rate with treating my rosacea patients.
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Do you use any sort of blood mapping technique to track progress of treatments?
I do not use any blood mapping technique in particular but I do take pictures and compare them with each visit. Another way I have done this is by pre-flushing the patients before each treatment and taking pictures. I have pictures of particular patients which show that with each succeeding treatment, the areas that flushed and the redness diminished with each treatment. I think this is what you may consider a crude blood mapping technique but it shows that the treatment worked!
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Dr Garcia-Lat,
Do you feel that IPL combined would levulan is an effective treatment for the papules and rough texure components of rosacea?
I have not tried using Levulan but I think it may help. I have heard of some people incorporating Levulan in their IPL treatments and they say it helps target the papules.
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Dr Garcia-Lat,
What is our experience with the fading of veins after IPL? Do they seem to take a while at times to be absorved by the body? What about the possibility of them blanching then coming back and fading again? Thanks for your time!
Many veins do fade and disappear after IPL. However, some of them may return or develop in other areas. When we close up some of them with IPL, new veins may develop in other areas. I liken this to a traffic jam. When the traffic is blocked or stopped in one area, the other small streets in the periphery get congested too because people are trying to find their way out. That is why it is important to come regularly for your treatments so that we can control them as they develop.
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I'm probably late to the party but I have a question if I could sneak it in?
I've tried 4 sessions of IPL in an effort to help the redness and skin texture problems I have.
Here are the parameters used:
Machine Used: Lumenis One
Skin Type: 3
Age Spots/Telangiectasia
560 Filter
17 Joules, 16 over the forehead
Double Pulse
(This next part might not make sense to some, and the forum removes the spaces that I'm using to make it look like they did on paper....sorry.)
4.0 l_l 4.0
__20.0___
It didn't help the redness and skin texture as much as I thought...I was kind of disappointed.
Next, we are incorporating Levulan. This will be mostly for skin texture...my skin is very coarse because of the rosacea. Does Levulan react better to a specific filter? Will these parameters need to be adjusted? I ask because it's a nurse that performs the procedure, she just presses a few buttons and the computer tells her what to do.
Thank you so much!!
It is very difficult to comment on the settings used. From what I can see, this protocol is how the machine was set and these are the settings used by Dr. Bitter, Jr. and Dr. Mulholland which are "double pulse". I sometimes use these settings on my "photorejuvenation" patients who have some spotty redness. For my rosacea patients, I use the settings of Dr. Bitter, Sr. which are mainly "triple pulse" and at much higher fluences. You cannot just follow the settings the machine spits out. A lot of times, my settings will depend on how my machine calibrates. There is a "fluence" bar in every machine and rather than state a particular number, I go by how the fluence bar is. I take it to the highest I can without burning the patient. I have been doing this a very long time and I know from experience what settings I can go to. Usually the pre-set machine settings are too conservative and if somebody not very experienced is doing this who does not understand the mechanics too well, then he or she will stay with the pre-set parameters in the machine to be safe. However, the patient may not get the optimal result.
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To all of you:
I hope I have helped answer some of your questions. Rosacea is a very puzzling disease and we really do not know the exact cause. To date there is NO cure. What we are doing with the IPL or "Photofacial" is a treament, not a cure. ( I do have 2 patients who claim they are "cured".) My goal in treatment is to help people suffering from rosacea live as normal a life as possible and to make their rosacea manageable and tolerable. I am happy when patients come back to tell me that they can now take a drink or so without flushing or do a presentation and not be "beefy red" or exercise. I have patients tell me they can now do some gardening whereas before it was impossible even to get out in the yard. I tailor my treatments to the what is bothering the patient most. For a lot of males it is the constant redness which they cannot cover with make-up like women do and for many others, it is the constant flushing. I use the more superficial filters for the redness and the deep ones for the flushing. Majority of the patients, though, suffer from both, so I would say that most of my patients get at least 2-3 passes with different filters. It is important to realize that one treatment will not do it and a series of 5-6 treatments is necessary to get optimal results. For some patients, more treatments are necessary before they achieve a significant result. Follow-up treatments are needed as well and when the symptoms tend to recur after several years, then one may have to get a series of treatments again. I have several patients who have had many IPL treatments elsewhere who told me that my first treatment did more for them than the series of treatments they had elsewhere. I do give a lot of "shots", though, comparatively, so that may have some bearing. I do feel for all of you out there and since this is the thrust of my "part-time" medical practice right now, I really take my time. I have learned a lot about the disease from my patients as well and I do not take anything for granted nor dismiss what they tell me. I have a better understanding of the disease now which is quite different from what we all learned years ago in med school. Rosacea has been a debilitating disease for some and if we can catch it early and prevent it from progressing, then it is well worth it.
As an aside, it has been reported in the literature very recently that scientists have found that people with rosacea have high levels of the anti microbial peptide cathelicidin in their skin and the proteins this produces cause the roasacea symptoms. These proteins are also different from those found in people who do not have the disease. They also found that patients with rosacea had too much of an enzyme called stratum corneum tryptic enzyme (SCTE), which converts cathelicidin into the immune system peptides that lead to rosacea. They injected laboratory mice with these substances and found increased inflammation of the skin. This is all very recent and with this discovery, it is hoped that scientists will now be able to work on a "cure" for rosacea.
Let us keep our fingers crossed and hope that indeed there will be a "cure" for rosacea soon. Good luck to all of you and thanks for giving me the opportunity to talk to you. If you have any further questions, do not hesitate to email or call me and I will try to answer as best as I can.
Dr. Zenda Garcia-Lat
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A big thank you to Dr Garcia-Lat for answering our questions!
Thanks so much for doing this for us, redhotoz, and a big thank you to Dr. Garcia-Lat as well.
This is very much appreciated!
You're welcome!
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