Rosacea is a progressive vascular disorder that affects the facial skin and eyes. It usually starts out quite innocently as a mild flush across the nose, cheeks, chin, and forehead. During the early stages, this flush comes and goes, seeming to have a mind of its own. As the disorder progresses, facial redness becomes more intense, taking on the appearance of mild sunburn or windburn. In areas of facial redness, tiny broken blood vessels and red bumps may also become visible. In the moderate to severe stages, facial inflammation usually intensifies, resulting in permanent redness, swelling, and burning sensations. In the most advanced cases, rosacea can cause facial disfigurement and disabling burning sensations.

Rosacea affects millions of people worldwide. In the United States an estimated 13 million Americans are afflicted by this disease (1 in 20 people). Personal communication with medical experts around the world indicates that other countries have large numbers of rosacea sufferers: Canada has an estimated 4 to 6 million rosacea sufferers, United Kingdom has an estimated 8 to 10 million sufferers, and millions more can be found throughout all parts of Europe, Ireland, Spain, China, Africa, and Russia
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Ten Major Symptoms of Rosacea:

1. Facial Redness: Facial redness is the most common symptom of rosacea. This is caused by hundreds of tiny dilated blood vessels near the surface of the facial skin.

2. Facial Telangiectasia (tel-an-jek-tasia): These are tiny broken blood vessels that are permanently fixed in the dilated state. These blood vessels take on the appearance of fine red lines coursing through the surface of the facial skin.

3. Facial Skin Hyper-Reactivity: Facial skin hyper-reactivity is caused by sensitive, inflamed blood vessels near the surface of the skin. These blood vessels dilate very easily to topical triggers and physical insults. It is important to note that the term 'sensitive skin' is misleading to rosacea sufferers because the problem is based on sensitive blood vessels, and not sensitive skin cells.

4. Lumpy-Bumpy Facial Skin: Uneven skin texture, or lumpy-bumpy facial skin is caused by dilated blood vessels, localized swelling, and leakage of inflammatory cells into the superficial layers of the skin.

5. Facial Papules: Facial papules are small, red bumps about the size of a pinhead. These bumps are caused by vascular flushing. Over time, flushing results in leakage of inflammatory cells out of the blood vessels and into the dermal skin. These inflammatory cells then migrate towards the surface of the skin, resulting in the inflammatory papules. Facial papules are not caused by bacteria or demodex mites.

6. Facial Pustules: Facial pustules are small red bumps with pus. These bumps are caused by vascular flushing in areas around sebaceous glands. Over time, flushing results in leakage of inflammatory cells out of the blood vessels and into the dermal skin. These inflammatory cells then migrate towards the sebaceous gland or pore, resulting in inflammatory pustules.

7. Facial Burning Sensations: Facial burning sensations are caused by activation of sensory pain nerves in the facial skin. These pain fibers are primarily triggered by the heat associated with increased blood flow. These nerve endings can also be activated by inflammatory substances that leak through blood vessels. After chronic activation, pain nerve fibers may become sensitized to other triggers such as skincare products and environmental insults (i.e., sun, wind, heat, and cold). Facial burning sensations can become severe in some sufferers, causing debilitation.

8. Facial Swelling: Facial swelling occurs when fluid and proteins leak out of facial blood vessels at abnormal rates. Frequent facial flushing leads to increased movement of water and proteins across abnormal blood vessel walls. Over time, this "spillage" overwhelms the lymphatic system (drainage vessels), and leads to fluid build up in the facial skin.

9. Rhinophyma: Rhinophyma is a form of rosacea that is characterized by chronic redness, inflammation, and increased tissue growth of the nose. Rhinophyma can take on many different forms. In most forms, the nose is chronically red and inflamed. There is also evidence of swelling, and the skin often shows thickened skin with large pores, resembling the peel of an orange (peau d'orange). In some forms, sebaceous gland hypertrophy and hyperplasia (increased growth and number of sebaceous glands) can cause the nose to grow considerably, resulting in a bulbous appearance.

10. Ocular Rosacea: More than half the rosacea sufferers that present with facial symptoms also have ocular rosacea. Ocular rosacea is primarily vascular in origin, but secondary changes may exacerbate the condition. Symptoms include inflammation of the eye surface, inflammation of the eye lids, scales or crusting on eye lids and eye lashes, blockage of the meibomian glands (blepharitis), dry eye syndrome, excessive tearing and blood shot eyes.

Rosacea Treatment Options

Traditional Treatments:

Traditional medical treatments include oral and topical antibiotics. Tetracycline derivatives such as Minocycline and Doxycycline are commonly used but do not treat the underlying vascular disorder. Furthermore, these antibiotics frequently cause side effects such as gastrointestinal upset, allergies, skin rashes and sensitivity to sunlight. Topical antibiotics such as Metronidazole – based products are often used to treat papules and pustules but can often cause redness, skin irritation and rashes. These antibiotics are not actually treating any infections, but are used to reduce inflammation. Therefore they usually do not heal the “ broken capillaries” or red bumps, but simply help prevent the inflammation associated with vascular damage and dermal inflammation. Many rosacea sufferers try to avoid the internal and external triggers that cause a “flare-up” but these are usually so numerous that it is almost impossible to avoid them all. Some of these triggers include temperature changes, alcohol, hot or spicy foods, exercise, and certain topical skin products. Other triggers are internal such as hormonal changes and emotional swings and are impossible to avoid.

New Treatments that Address the Underlying Disorder:

Treatments with the Intense Pulsed Light devices are designed to eliminate the “broken blood vessels”, hyper-reactive blood vessels, the small red bumps and the smaller capillaries that cause flushing. Dr. Clinton uses “second pass” 1064 YAG laser which has dramatically increased the efficacy of the treatments by penetrating deeper into the dermis to eliminate the larger feeder blood vessels which cause flushing. Once the unsightly telangiectasia (spider veins) and small red bumps are removed, flare-ups are dramatically reduced. In addition the inflammatory process that causes scarring of the nose and cheeks is stopped. Flushing is harder to completely eliminate but can be significantly reduced. The treatment itself helps to smooth the skin and repair some of the damage caused by Rosacea. Significant clearing usually takes 6 or more treatments but improvement is seen with each treatment. Occasionally, more difficult cases can take 10-15 treatments to clear if the rosacea is severe.

Flushing Protocol:

A new flushing protocol has been recently developed. By inducing intense flushing in patients who suffer from this problem just prior to treatment and then using a triple pass technique with three different wavelengths, dramatic improvements can be achieved in both flushing intensity, pain and facial burning sensations. Multiple treatments can be performed in a short period of time (as many as three per week) and our experience has shown that significant improvement occurs with each treatment. By performing these treatments closer together neovascularity (growth of new blood vessels after a treatment) can be minimized. Flushing can be induced prior to or during treatment and the heat produced by several treatment techniques. Improvements in flushing are quite obvious during these treatments because our ability to induce a strong flush with dilators is often diminished or attenuated after 4 to 6 treatments. In other words we have to work harder after each treatment to generate a treatable flush. Many patients will schedule three of these extensive treatments in a single week or even six treatments in a two week period. Additional developments to minimize post treatment redness and swelling have enabled us to offer this concentrated therapeutic intervention. This regimen can also be used to effectively treat all other forms of rosacea.

Concentrated Treatment Protocol:

For patients who desire an intense concentrated treatment regimen I have developed the concentrated treatment protocol. This consists of a rosacea treatment every two to three days for one to three weeks. By employing this protocol patients can get a significant amount of clearing in a very short time. While it was developed for patients with flushing problems it can be used to treat all symptoms of rosacea. The laser and intense pulsed light settings are designed to impart the maximum amount of energy to the target tissue without causing significant post treatment redness or swelling. Blistering and bruising are extremely rare with these techniques. Many patients can resume normal daily activities immediately after the treatment. Additional precautions to reduce the chances of redness and swelling may include the use of ice, low salt diet, upright positioning of the head and occasionally an antibiotic that reduces angiogenesis (Clarithromycin XL). This protocol allows patients to achieve dramatic reductions in their symptoms in a very short period of time.

Triple Pass Treatment Protocol:

By utilizing the 1064 Yag laser and several wavelengths on the Intense Pulsed Light Device different depths can be treated in a single treatment session. This enhances the efficiency and efficacy dramatically allowing greater clearing in fewer treatment sessions. The pathologic vessels causing rosacea occur in at least three different levels in the skin and each level must be treated. It must be stressed that if the deeper feeder vessels are not treated then the true cause of flushing will never be improved
Total perfection is not always attainable. Once clearing has occurred rosacea medications, such as Metrogel and tetracycline can often be discontinued. Touch up treatments may need to be performed every annually to keep the rosacea under control. Appointments are usually scheduled 2-4 weeks apart until the desired results are achieved. However for patients who travel from outside the area, two to three treatments may be administered weekly during an extended stay.

Traumatically induced ( Iatrogenic ) Rosacea:

This occurs when a rosacea patient has been made medically worse by certain procedures and treatment regimens . In general these procedures remove the outer layer of skin leaving the underlying layers exposed and vulnerable. These procedures include CO2 and Erbium laser resurfacing; deep chemical or acid peels; deep dermabrasion or any procedure that deeply removes the outer layers of skin. Other regimens which may cause pathologic thinning of the skin include frequent applications of high dose topical steroids (cortisone) used over many years. While the steroids may improve symptoms for the short term they may permanently thin the outer layer of skin. Severe rosacea sufferers have extremely thinned skin anyway and these regimens can induce a chronic state which is severe and disabling almost like a burn victim. These unfortunate individuals do not respond to the routine laser, IPL or medical treatments that help other rosacea sufferers. There is hope now for these patients. Noninvasive collagen stimulating lasers can thicken the dermis and epidermis; however, many treatments are usually needed (10 to 15)at the least.

Response of Rosacea Symptoms to Treatment Protocols

Facial Telangiectasia (tel-an-jek-tasias): The facial spider veins are very easy to treat with the latest devices. In fact they are fun because they disappear so easily. They may have to be treated more than once but in general they are the easiest aspect of rosacea to eliminate.

Redness: Redness can be reduced and even eliminated given enough treatments with the Triple Pass Therapy. It is important to treat all the vascular levels with several different wavelengths. If facial redness only occurs during flushing episodes it is imperative to induce flushing prior to and during treatment.

Flushing: The key to treating flushing is to induce it during the treatment and maintain it while treating each vascular level with different wavelengths. The laser/IPL devices cannot treat what they cannot see. Redness and flushing respond especially well to the concentrated treatment protocols with 2-3 treatments performed in a one week period. While it is hard to completely eliminate flushing it can almost always be significantly reduced for extended periods.

Burning and Pain: Burning and pain generally occur in association with flushing. By reducing flushing the pain and burning are usually reduced. However in rare cases pain and burning are not associated with flushing and in these cases improvement is less predictable. In addition if a pain pattern has been established for some time then it may not disappear as flushing resolves. In general it is worthwhile to aggressively treat these patients early on in order to try to alleviate these symptoms.

Papules and Pustules: These can be virtually eliminated given enough treatments. While more treatments are usually required for the successful treatment of pustular rosacea, long term remissions can be achieved and sustained with the occasional touchup treatment. This smoothing process occurs gradually over time and continues beyond the course of treatments.

Facial Swelling: Facial swelling will gradually resolve with the resolution of other symptoms as the source of inflammation is removed; however in patients with facial lymphatic problems, facial swelling is extremely hard to treat.

Rhinophyma: Markedly enlarged deformed noses cannot be improved by these techniques but can be prevented if caught in the early stages of deformity. The more severe forms require accutane and surgery.

Rosacea Treatment Instruction Overview

Before your treatment: It is crucial to avoid tanning and tanning solutions before the treatment because this reduces the ability of light to penetrate the skin. It also increases the risk of side effects such as redness, swelling and blistering. If you are going to be in the sun wear a hat and 30+ SPF sunscreens. Aspirin, Ibuprofen, anti-inflammatories, many naturopathic and vitamin supplements and steroid use can increase the risks of bruising and swelling and should be avoided for one week before and after each treatment. Tylenol is OK to use. It is very helpful to induce flushing before treatment so that the device can “see” and eliminate more of the “broken capillaries”. This can be accomplished with 100 mg of Niacin, exercise, or hot beverages one hour prior to treatment. If your rosacea is at it’s worst prior to treatment then you will get the best results by eliminating the most “target tissue”. Therefore it also makes sense to discontinue topical and oral treatments 1-2 weeks prior to your scheduled appointment.

The Treatment: The treatment is performed with an intense pulsed light device (IPL) and the 1064 YAG Genesis laser. These devices generate an intense light that destroys the “broken capillaries” at different depths while sparing the normal skin. The treatment takes about thirty to ninety minutes and can easily cover the entire face. The neck, upper chest and ears can be added for an additional fee. The intense pulsed light treatment feels like a rubber band snap and there is usually no pain after the treatment. The Genesis treatments are less intense. All the affected areas are treated several times during the course of the treatment in order to maximize results. The doctor can see the spider veins disappearing during the course of the treatment and treat them.

After the Treatment: Cortisone cream will sometimes be applied one time to help reduce redness and swelling at the conclusion of your treatment. Ice may also be applied for the first day or two. Swelling can be minimized by treating with ice, by avoiding salty foods and by sleeping with the head of the bed elevated. Redness may persist for several hours to several days. Direct sun exposure should be avoided for 1 week after treatment. Wear a sun block on a daily basis which can be applied after makeup. Do not tan between treatments. You will need to wait at least one month after tanning or using tanning solutions to continue your treatments. Blistering may occur, but this is a rare side effect. If a blister occurs you can apply a moisturizer such as aloe vera or vitamin E cream. It is important not to let the blister dry out. Please notify our office if a blister or significant swelling occurs. Clarithromycin XL ( Biaxin XL) may be used after a treatment or series of treatments. It is an oral antibiotic similar to erythromycin. It helps to reduce swelling, prevents angiogenesis (growth of new blood vessels) and helps to prevent post treatment flare-ups of the rosacea after a treatment.

Specific Before & After Treatment Instruction

Before Treatment:
• Avoid tanning and tanning solutions 1-2 months prior to treatment and between treatments.
• Avoid aspirin, Ibuprophen, anti-inflammatory medications, certain OTC supplements (grape seed extract, pycnogenol, Ester-C, Vitamin E,Ginko Biloba, Ginseng) and steroids for 1 week to help prevent bruising and swelling.
• Take 100 mg. of Niacin, a hot beverage, or exercise to induce flushing before treatment.
• Discontinue prescribed topical and oral rosacea medications 1-2 weeks before treatment to help enhance the treatment (unless otherwise arranged)

After Treatment:
• Apply ice after treatment to reduce the chances of swelling.
• Redness may last from several hours to several days.
• Avoid tanning and tanning solutions for 1-2 weeks after the last treatment.
• Avoid hot tubbing for at least a month after treatment to prevent flushing and subsequent infections. If the skin is broken or a blister appears use Vitamin E or aloe vera to prevent the area from becoming dry.
• Allow 2-4 weeks for the next treatment, 2-3 treatments can be performed in one week if tolerated.
• Improvement is seen with each treatment but significant clearing takes at least 6 treatments. Difficult or severe cases may take 10-15 treatments to clear. After the final treatment, the skin continues to improve for one to three months.

Insurance Reimbursement:

While insurance may reimburse for the rosacea treatments,payments are made directly to Timeless Skin Solutions from the patients and from the insurance company to the patient.