3. PHOTODERM


In 1995, Photoderm (Photoderm VL/PL: ESC Medical Systems) was given FDA clearance for the treatment of facial blood vessels. Photoderm is a novel intense pulsed light source (noncoherent light) that was the result of new technological advancements in the field of lasers. This system was designed to emit pulsed light that can be "tuned" to treat facial blood vessels of different sizes, shapes, thicknesses, and skin depths. In the hands of an experienced specialist, photoderm can be a powerful weapon against facial vascular disorders.



Treatment of Blood Vessels with Photoderm


• In a photoderm study on 159 patients with dilated blood vessels, excellent clearance was achieved in 79% of the treated blood vessels. (148) No major side effects were noted. Side effects were generally mild and transient.

• In a recent clinical study, medical specialists demonstrated that photoderm is able to treat damaged facial blood vessels that are resistant to pulsed dye laser treatment. In this study, photoderm treatment resulted in complete clearance of over 90% of the blood vessels. (149)

• Dr. Raulin and colleagues recently demonstrated that photoderm is an excellent form of treatment for facial telangiectasia. (150) Out of 14 patients, 10 showed excellent results, 3 showed good results, and only 1 patient responded fairly.

• Clinical photographs submitted by Dr. Beverly Kemsley of Canada, and Dr. David Wilder of Germany, demonstrate that facial telangiectasia of different sizes can be effectively cleared with photoderm. (151)



Treatment of Facial Port-Wine
Stains (Red Vascular Birthmarks)


• In the medical study, “Effective Treatment of a Laser-Resistant Port Wine Stain with Photoderm VL Therapy,” photoderm specialists demonstrate that deep port-wine stains that are resistant to laser therapy can be successfully cleared with photoderm. (152)

• A study by Dr. Raulin and colleagues on 37 patients (with 40 port-wine stains) demonstrated that photoderm treatment results in very good to excellent clearance of this vascular disorder. (153) In this study, photoderm cleared blood vessels that were previously unresponsive to standard laser (seven of the port wine stains were unsuccessfully treated in the past by pulsed dye laser or argon laser).

• In the study, “Effective Resolution of a Mature Port-Wine Stain using Photoderm VL”, photoderm specialists documented 90% clearing of a very intense, hard-to-treat port-wine stain. (154)

• Clinical photographs submitted by Dr. Phillip Bandel of Texas, and Dr. Christian Raulin of Germany, demonstrate that deep facial port-wine stains can be effectively cleared by Photoderm. (151)



Advantages of Photoderm over Pulsed Dye Laser


1. Photoderm is able to treat blood vessels at different depths in the facial skin: One of the key advantages that photoderm has over pulsed dye lasers is that it is able to treat blood vessels at different levels in the skin. Superficial blood vessels are treated with 550 and 570 wavelengths, medium-depth blood vessels are treated with the 590 wavelength, and deep vessels can be cleared with the 645 wavelength.

Vascular specialists emphasize that one of the keys to treating flushing disorders lies in the ability to treat both superficial and deep facial blood vessels. (155, 156) The goal of treatment is to selectively target different vascular beds in the facial skin by selecting the optimal wavelength that corresponds to the depth of the blood vessels. (157) This is where photoderm has no rivals. It is currently the only computerized device with over 20 million potential settings to fine tune treatment.

Regarding the treatment of deep vessels, photoderm is able to penetrate up to 3-mm deep into the skin, which is over twice as deep as the 1.2-mm depth of traditional pulsed dye lasers. (144, 157) Clinical studies demonstrate that photoderm is very effective at clearing dilated facial blood vessels deep within the dermal skin (vessels that cannot be reached by traditional pulsed dye lasers). (157)

2. Photoderm is able to treat thick-walled vessels: Another key advantage that photoderm has over pulsed dye lasers is that it is able to deliver multiple pulses of light energy to the blood vessels (1, 2 or 3 pulses); pulsed dye lasers can only emit one brief pulse of laser light. Double and triple pulsing with photoderm allows more light energy to be delivered to the vessels without heating up the surrounding tissue. This gives photoderm a significant advantage, because it is able to deliver enough light energy to treat thick-walled blood vessels. (144, 150) Photoderm experts state, “The first pulse will destroy the top part of the vessel and the second pulse, which comes immediately after, destroys the other part of the vessel. Other types of laser therapy fail to destroy the entire vessel because they can only deliver energy to the very top layer of the blood vessel.” (158)

Dr. Mitchel Goldman, a dermatologic surgeon and international expert in lasers states, “Photoderm is able to thermocoagulate blood vessels 10 times larger than those previously treated with pulsed dye laser therapy.” (158) Dr. Goldman further predicts, “Photoderm technology represents the next generation of laser-like treatments and has the potential of revolutionizing the treatment of skin-related blood vessel disorders.” (158)



Important



General rosacea studies indicate that rosacea is primarily a disorder of superficial thin blood vessels. So, what is the importance of treating thick-walled facial blood vessels? Well, as vascular experts are now demonstrating, thick-walled feed vessels are of primary importance to vascular flushing disorders. (159-164) These thick-walled blood vessels serve as “highways” for large volumes of blood flow to the surface of the skin. These thick-walled vessels consist of normal feed vessels that deliver blood to the surface microvessels, and thermoregulatory shunt vessels that are important in nerve-mediated flushing. These thick-walled blood vessels are in great abundance in areas of the face such as the nose, cheeks, and forehead (primary areas of importance for rosacea development). (159-164)

Vascular specialists point out two specific reasons why laser treatment should target thick-walled feed vessels and thermoregulatory shunts:

For greater reduction in the flushing response: If laser systems cannot target thick feed vessels and thermoregulatory shunts, then a good portion of the flush response will remain intact in rosacea sufferers. No matter how experienced laser surgeons are, they are only as good as the laser they are holding in their hands. If they are handicapped by older laser technology, then they will not be able to target some of the important feed vessels, limiting the overall success of the treatment.

For longer-lasting results: Laser specialists that only treat superficial thin microvessels are leaving behind feed vessels that supply the skin with large volumes of blood. Over time, repeated flushing of the larger feed vessels will overwhelm the smaller surface vessels and cause gradual return of rosacea symptoms. The goal of any laser treatment should be to permanently decrease the entire vascularity of the face. This cannot be achieved without targeting some of the deeper, thick-walled blood vessels.



3. Photoderm treatment is associated with fewer side effects: Another advantage that photoderm has over traditional pulsed dye lasers is that photoderm treatment is associated with fewer side effects. The ability of the photoderm to “tune” into blood vessels at specific depths in the skin, and to deliver heat in a more gradual fashion (i.e., multiple pulses) enables photoderm to treat facial blood vessels without blackish/blue bruising, severe swelling reactions, or crusting and blistering. (144, 165)

• In a 1999 medical article in the Journal of Cutaneous Laser Therapy titled, “Treatment of Facial Vascular Lesions with Intense Pulsed Light”, Dr. Marla Angermeier, Clinical Assistant Professor, Dept. of Dermatology, Brown University, reviewed her results of 2 years of photoderm treatment on facial blood vessels. (166) A total of 200 patients were treated for facial telangiectasia, rosacea, and port-wine stains. Of the 188 patients who returned for follow-ups, 174 achieved 75% to 100% clearance in one to four treatments. She states, “The post-treatment side effects were minimal and well tolerated by the patients. There were no instances of scarring or other permanent side effects.” (166) She concludes, “The Photoderm VL provides a highly effective and safe alternative to the laser for treatment of facial vascular lesions. The device may achieve improved results for lesions that are resistant to laser therapy. The rate and degree of cosmetic side effects are considerably less than with laser treatment.” (166)

• In a different clinical study, Drs. Schroeter and Neumann evaluated 120 patients who were treated with photoderm. (149) They found that side effects were usually mild and transient in nature.

4. Photoderm has a very large treatment crystal: Photoderm has an extremely large-sized treatment crystal (rectangle of 8 mm x 35 mm); traditional pulsed dye lasers only have a small 5-mm round spot treatment area (smaller than a pencil eraser). So, photoderm can cover much larger areas of skin with each pulse. This larger-sized crystal also decreases the chance of ‘missing’ areas of blood vessels, and allows for more selective treatment of blood vessels. The increased photoderm spot size  decreases scattering of light  which allows for better penetration through the epidermis. (167)

5. Photoderm treatment is associated with much less pain: Dr. Goldman states that his patients usually report much less pain with photoderm (as compared to pulsed dye laser). (145) I am in total agreement with his report. In my experience, photoderm treatment is much gentler than traditional pulsed dye laser treatment.



Comparison of Photoderm to Pulsed Dye Laser
(Computer Simulation)



Recently, Photoderm VL was compared to the pulsed dye laser (585-nanometer) in a theoretical computer simulation. (168) Comparisons were made on the effect of treatment on four different blood vessels (different sizes and skin depths):


• 2 small microvessels (0.05-mm diameter), very close to the skin (0.3-mm and 0.4-mm deep).

• 1 medium size vessel (0.5-mm diameter), located deeper in the skin (0.6-mm deep).

• 1 large vessel (1.0-mm diameter), located very deep in the skin (1.0-mm deep).

Results of the pulsed dye laser treatment:

• The 2 small superficial blood vessels were treated; but, in doing so, they were both heated beyond the boiling point, resulting in bursting and purpura.

• The medium- and large-sized vessels were relatively unaffected. The pulsed dye laser only heated a small layer across the top of these vessels.

• The epidermis reached 85 degrees centigrade, which resulted in bruising and hyperpigmentation.

Results of the photoderm VL treatment using triple pulses:

• The 2 small blood vessels were successfully treated without causing bursting and purpura.

• The medium- and large-sized vessels were heated across the entire cross section to cause complete coagulation.

• The epidermis was not heated and thus did not cause any bruising, hyperpigmentation, or skin damage.

Rosacea Treatment with Photoderm

Photoderm has already been used with great success on thousands of rosacea sufferers:



• In a 1999 clinical study on the effectiveness of Photoderm VL on 74 rosacea patients, Dr. Angermeier reported 75% to 100% clearance in rosacea symptoms in one to four treatments. (166) Furthermore, three rosacea sufferers who were unsuccessfully treated in the past with pulsed dye laser, experienced 75% clearance of their rosacea after only a single photoderm treatment.

• Dr. Jerry Darm, a photoderm specialist at Preventive Medicine Associates, states, “Rosacea can now be treated with Photoderm. Generally, after two to three treatment sessions remarkable results can be achieved. Many patients who have struggled for several years with other modalities, have gotten complete remission from the disfiguring disorder.” (169) In the last two years, Dr. Darm and his staff have treated over 500 rosacea patients. Dr. Darm’s internet address is: (http://pma-nw.com/rosaceamain.htm).

• Dr. Joel Schlessinger, an internationally recognized dermatologist and laser expert has treated over 1000 rosacea sufferers with photoderm (personal communication). His rosacea patients usually report excellent clearance of facial telangiectasia and redness, and significant reductions in facial flushing. Many of his patients also experience long-lasting relief from the burning face. Typically, his patients are satisfied after 3 to 4 treatments, with about 50% clearance of rosacea symptoms per session. That is 50% reduction in rosacea symptoms after the first treatment, and then 50% reduction of the remaining rosacea, etc. He also reports excellent results with the treatment of deeper blood vessels. In our communications, he is quoted as stating, “I do have experience with the pulse dye laser in my practice and was not impressed at all. First, it causes terrible bruising and second, it doesn’t have the range of wavelengths so it just doesn’t seem to get the same results for rosacea. With the photoderm, our settings are not found on the machine – we tailor them from patient to patient”. Dr. Schlessinger also points out one last important point, “The great thing about photoderm is that it does its thing without any down time.” Dr. Schlessinger is practicing with Skin Specialists, P.C. in Omaha, Nebraska. His internet address is: (www.skindeepusa.com).


• Dr. Harvey Jay, a Clinical Assistant Professor of Dermatology at Cornell Medical School, has been using pulsed light technology (photoderm and epilight) for close to 6 years now. He has performed thousands of successful treatments and teaches other physicians from around the world on the use of photoderm technology. In a recent personal interview that I conducted with Dr. Jay, he stated, “I find treatment of facial blood vessels and rosacea to be very successful. Virtually every patient I treat experiences significant improvement.” His patients normally need one to four treatments and in his estimate, “Facial telangiectasia clears by about 90% and the rosacea erythema (smaller microvessels) usually clears by approximately 80%.” He also states, “My patients usually report fewer papules and pustules after treatment.” It is important to note that less than 1% of his patients experience bruising. Dr. Jay also reports excellent success with deep, thick-walled blood vessels, and tiny, superficial microvessels. Dr. Jay cautions that, “Completely different settings are needed to treat these different vessels”. In fact, many of his rosacea patients have come to him after other laser treatment systems have been tried with minimal success. He concludes, “My patient satisfaction is extremely high and long-lasting.” Dr. Harvy Jay is practicing in New York, NY. His internet address is: (www.mdlaserderm.com).

• Dr. Graham Kelly, Medical director of the Vein Clinic at Lansing, is quoted as saying “I think the single most gratifying results of photoderm is in treating rosacea.” (170)

• Dr. Alice Gale, a dermatologist and photoderm specialist, indicates that photoderm is an excellent form of treatment for rosacea sufferers, and states that compared to all other lasers currently available, “It is the most beneficial”. (170)

• In a case study of a rosacea patient who had suffered with rosacea for 15 years, physicians documented that after two treatments with photoderm, chronic facial redness and telangiectasia cleared by approximately 95%. (171)

• In the Photoderm Clinical Casebook, Dr. Graham Kelly of USA, Dr. Beverly Kemsley of Canada, and Dr. Ki-Shik Shin of S. Korea submitted clinical before and after photographs of rosacea patients demonstrating very good to excellent clearance of rosacea. (151)

• In the study, “Treatment of Benign Vascular Lesions with the Photoderm VL High-Intensity Pulsed Light Source”, Dr. Mitchell Goldman published photographs of a patient with dense facial telangiectasia and chronic skin redness. (172) The patient showed excellent clearance of telangiectasia and a significant decrease in facial redness after only one photoderm treatment.

• In a rosacea case study, photoderm specialists discuss one of their patients. (170) They reported that Mrs. Frey, an elementary school teacher, was extremely distraught by her disfiguring disease. She reported incidents where her students innocently remarked, “Mrs. Frey your nose is red, you look like Rudolph”, and times when her faculty members would tease her that she was drinking in between classes. She also stated, “In the summertime people thought I had a sunburn”. After 4 treatments with photoderm, the clearance was dramatic -- it resulted in complete clearance of her rosacea. She personally reported, “It looks wonderful!” (170)


Limitations of Photoderm

While photoderm is able to theoretically treat facial blood vessels of different sizes, depths and thicknesses (effectively reducing rosacea telangiectasia, chronic redness, flushing, swelling, burning, and skin hypersensitivity), it takes an experienced photoderm specialist to find the right treatment parameters for individual rosacea patients. The photoderm specialist must have extensive experience with rosacea cases in order to ensure maximal results.

It is extremely important that rosacea sufferers find an experienced photoderm physician, one that has experience in treating cases exactly like theirs.

In personal communication with Dr. Joel Schlessinger of Nebraska (who has treated over 1,000 rosacea sufferers), he states, “The unfortunate thing about photoderm treatment of rosacea is that results vary significantly from operator to operator. You really can’t say that just because someone has a photoderm that they can treat rosacea. You must be warned – just because someone has a photoderm machine, it doesn’t mean that he or she is an expert. Make the physician show pictures of their own results, and if they don’t have pictures I would be very leary of going there.”



Common Side Effects of Photoderm

Photoderm treatment does not usually result in purpura, crusting, blistering, or severe swelling. (150) This is one of the big advantages of Photoderm; there is usually no ‘down time’ after treatment. Patients may experience mild, transient side effects such as facial redness, mild swelling, and facial discomfort.


Photoderm Treatment for Sensitive Skin

In personal communication with over a dozen photoderm specialists, and many of their patients, it has become quite clear that double and triple pulsing with photoderm offers the most gentle treatment for rosacea skin and blood vessels. Double and triple pulsing (with conservative pulse durations and delays) results in slow, gentle heating of blood vessels  decreasing the chance for blood vessel rupture, heat escape into surrounding tissue, epidermal damage, and irritation to sensory pain neurons.



My Personal Experience with Photoderm

I was treated with photoderm during the very early days of its inception, when everything was brand new and experimental. Photoderm was one of the single best treatments for my rosacea and facial flushing. In my particular case, I was treated 6 times over a period of 5 months. Photoderm treatment:

• Completely cleared my facial telangiectasia and reduced my chronic facial redness by 90%.

• Signficiantly reduced my facial swelling, burning sensations, and skin hypersensitivity.

• Significantly reduced facial flushing to many of my mild to moderate triggers. It reduced the frequency, intensity and duration of these flushes.

• Reduced my facial papules by about 70%.

• Helped to normalize my early stage rhinophyma.




Photoderm and My Personal Flushing Protocol


In order to maximize my results, I spoke to several vascular experts about the best theoretical treatment protocols. I came to the conclusion that for the best results, I would have to actively treat my underlying flush. This meant that superficial and deep vessels would need to be ‘open’ during treatment so that photoderm could ‘tune’ into them. To ensure that the blood vessels were dilated, I would need to induce a facial flush prior to treatment:

For inducing a superficial flush, I experimented with topical dilators in my lab (acetylcholine & adenosine), and topical niacin-based products (nioxin, nioxin research laboratories). I found that I could induce an impressive 30-minute flush with topical nioxin.

For inducing a deep flush, I experimented with body heating, and holding hot coffee in my mouth (these both opened up large, thermoregulatory shunt vessels in my facial skin). I found that I could induce an intense, deep flush by drinking a cup of hot coffee and holding the coffee in my mouth for 6 to 8 seconds before each swallow.

Although my results are only anecdotal, superficial and deep flushing protocols do hold great potential for more complete reductions in facial flushing.