As dermatologists, we are aware of the standard presentations of and treatments for rosacea. However, there are many patients for whom the significance of the disorder is far more than just facial redness, prominent blood vessels, papules and pustules, flushing and/or rhinophyma.
Over the past 12 years, I have treated several patients whose rosacea symptoms and appearance have partially or totally disrupted their lives as a result of the pain, burning, stinging and/or tingling symptoms in addition to the social embarrassment caused by their extreme redness and/or flushing. Usually, their medical workups have been negative for other systemic diseases, and they have seen several dermatologists and other physicians without significant improvement.
The following seven case histories demonstrate the extent to which these problems have impacted their lives and the dramatic improvement possible using a treatment protocol that I have developed that includes intense pulsed light (IPL).
Patient 1: Pain Worse Than the Severe Redness
Susan N. is a 63-year-old female, Fitzpatrick skin type III, who has had rosacea for 4 years involving her cheeks, nose and ears.
Symptoms and Degree of Debility
In spite of Susan’s dramatically purple-red baseline color (See Figure 1), her primary complaint was “painful burning” associated with her flushing. She said she would “rock in pain” for 4 to 5 days at a time. As these flares prevented her from even talking on the phone, she left her secretarial job and went on disability. She couldn’t leave her house during the daytime because of the extreme severity of her appearance and symptoms.
Previous Treatment
Susan saw four previous dermatologists, had two biopsies and a complete medical workup at two Manhattan medical centers to establish her diagnosis of rosacea. She was treated unsuccessfully with beta-blockers, tetracycline, antihistamines, antidepressants (such as Amitriptyline) and acupuncture.
Treatment Results
Since her IPL treatments, her flares last 30 minutes or less and she says she can now “function with the pain and work through the pain.” Her original bright purple-red cheeks are now pink and her flushing is much less red. She now can leave her house to take a bus to go shopping. She recently took her first trip since developing rosacea to Florida’s hot climate to visit her grandchildren.
Her stinging and tingling, which occurred daily before IPL treatments, now occur only rarely — once a month or less frequently.
Patient 2: Painful Burning
Brian R. is a 54-year-old male, Fitzpatrick skin type III, whose rosacea started 1 year prior to presenting to my office.
Symptoms
His first symptom was painful burning. He also had increased baseline redness and flushing. His problem affected his cheeks and nose, flared with exercise, stress and heat, and interfered with his work as a teacher.
His painful burning lasted for 4 to 10 hours each day, and each flare persisted for 5 to 7 days. Brian had previously undergone three “painful” pulsed dye laser treatments, which produced bruising with only slight improvement in the redness.
Treatment
Brian was the first patient I treated with IPL specifically for the symptoms of painful burning. He received a total of 14 IPL treatments with no adverse effects.
Results
In March 2007, 3 years after his final treatment, he reported that his rosacea is gone — he has no more pain, redness or burning. “My skin is just right ... like the skin I had at age 30,” he said.
Patient 3: Burning, Stinging, Tingling and Flushing
Nancy L. is a 51-year-old female, Fitzpatrick skin type II.
Symptoms and Prior Treatment
This patient had a 20-year history of rosacea involving her cheeks, chin, forehead and nose. She had increased baseline redness, distinct blood vessels, burning, stinging and tingling. She presented to my office 7 months after her second ineffective IPL treatment by another dermatologist.
Treatment and Results
After five IPL treatments, her burning, stinging and tingling cleared, and her flushing was much improved. (See Figure 2.) She had no side effects from treatment, while her blood vessels and redness had a “dramatic response” from four IPL treatments.
Patient 4: Burning, Flushing and Swelling
Fran S. is a 33-year-old female, Fitzpatrick skin type V, whose 6 months of rosacea symptoms compelled her to leave her teaching job.
Symptoms and Prior Treatment
Her primary complaint was the burning and flushing, which were sometimes followed by swelling. The burning occurred on her cheeks, chin and nose. The flushing was limited to her cheeks and nose. Both symptoms occurred every night for approximately 3 hours and were produced by changes in temperature, especially increases. She also had increased baseline redness of her cheeks, as well as her chin and nose, though less severe.
Ineffective treatments with Solodyn, Zyrtec (40 mg) qd and Protopic 0.1% ointment were stopped. Treatment with Effexor produced a 50% decrease in flushing duration and severity. She was also taking Claritin qd.
Treatment and Results
I treated Fran with IPL because she felt that her improvement from taking Effexor was not sufficient.
The three IPL treatments I administered every 3 weeks produced a dramatic change in her quality of life. Her burning and tingling resolved immediately after the third IPL treatment and her flushing cleared 1 week later. Her redness decreased in all treated areas and warm conditions became less problematic and no longer curtailed her outdoor activities.
She now plans to resume teaching in September 2007.
Patient 5: Burning, Tingling, Redness, plus Pimples
Steve L. is a 35-year-old male, Fitzpatrick skin type IV, with a 1-year history of rosacea on his cheeks and nose.
Symptoms
He experiences burning and tingling, increased baseline redness and blood vessels, and papules and pustules. Flares are produced by either hot or cold temperature changes, increased humidity, exercise or increased stress.
Prior Treatment
Differin gel, Metrogel, Elidel cream and Novacort were ineffective.
He was placed on doxycycline 150 mg qd by his local dermatologist 4 months before seeing me and continued taking this dose.
Treatment and Results
I treated his papules and pustules with alternate-day, once-daily treatments of Differin 0.1% cream or Clindamax 1% lotion to opposite sides of his face to test the patient’s response.
Steve’s burning cleared after one IPL treatment; after four IPL treatments, three out of the four areas of tingling have cleared and his tingling has become less frequent and severe. He has areas of clearing and diminished redness, as well as a decrease in distinct vessels.
His progressive improvement occurred during a period of increasingly warmer weather despite his history of heat intolerance.
Patient 6: Symptoms Include Burning, Flushing, Redness
Linda Q. is a 34-year-old female, Fitzpatrick skin type 4, with a 7-year history of rosacea involving her cheeks, nose and forehead.
Symptoms and Prior Treatment
Her primary problems were her burning, flushing and redness that flared with stress, alcohol, heat and caffeine.
Linda had seen eight previous dermatologists without improvement in her rosacea. She was unsuccessfully treated with oral tetracycline, doxycycline, and topical clindamycin, Klaron lotion, Noritate cream and Avar.
Her burning cleared after I performed six IPL treatments. Her flushing and redness markedly improved as well. (See Figure 3.)
Linda considered the IPL treatments a cure more than a treatment because she was able to wean herself off medication without side effects.
Patient 7: Incapacitating Facial Burning, Flushing and Erythromelalgia
Barbara S. is a 34-year-old female, Fitzpatrick skin type II, with a 10-year history of rosacea.
Rosacea Symptoms
She experienced severe incapacitating facial burning sensations primarily on her cheeks. The burning was so severe, she found herself unable to concentrate on anything other than the pain. The burning was usually followed by facial flushing.
Quality-of-Life Issues
Barbara’s condition severely impacted her quality of life. Each time she flared, she felt driven to stop everything and cool down with cool water compresses and air conditioning . She kept her scalp hair very short in length because she believed it “trapped heat.” Irritation prevented her from applying or using any product on her face. Kitchen heat prevented her from cooking. Factors such as foods, stress, change in room temperature and sleeping without her head elevated all produced a flare in her rosacea.
Treatment Results
After IPL treatments, she is now improved to the extent she can live normally. (See Figure 4.) The degree of her discomfort and the intensity and duration of her symptoms have all diminished. The threshold for her flaring has increased. She can now cook and go outdoors in warm weather, and can now sleep with minimal discomfort during the night. The scalp irritation associated with coloring her hair, the ear irritation associated with wearing earrings, and the neck inflammation associated with wearing clothes such as turtlenecks have all been resolved after IPL treatments to her face, ears and neck.
As an added benefit, her previously dry and scaly facial skin has improved with IPL treatment, and she finds her skin softer, smoother and more even- toned in appearance.
Most Medications Discontinued
Barbara, who was also diagnosed approximately 2 years ago with erythromelalgia involving her hands and feet, is currently taking only two medications: Doryx 100 mg bid and Evoclin foam qd to her face and neck for papules and pustules. She has been able to discontinue medications found to be ineffective, such as Noritate cream, clonidine and Klonopin.
She has also stopped the following medications because of their side effects: Zyrtec, Lyrica, Zoloft, Neurontin, Elidel cream, Metrocream and Mimyx cream.
SUMMARY
In summary, these seven case studies demonstrate that:
1. Rosacea can have more debilitating symptoms than routinely ascribed to it by dermatologists. These symptoms can interfere with and even completely disrupt the lives of these patients.
2. Conservative IPL treatments, alone or in combination with systemic and/or topical medication, can significantly ameliorate the symptoms and signs of refractory rosacea, enabling patients to regain their prior high quality of life.
In subsequent articles I will outline my protocol and plans for treating these patients based on my past 12 years of using IPL in the treatment of this often debilitating malady.
