Med Lasers 2024; 13(1): 54-57  https://doi.org/10.25289/ML.24.001
Intense pulsed light as an alternative treatment for erythematotelangiectatic rosacea: a case report
Jiwon Lee1, Sang Ju Lee2, Han Kyoung Cho1
1Department of Dermatology, Myongji Hospital, Goyang, Republic of Korea
2Yonsei Star Skin & Laser Clinic, Seoul, Republic of Korea
Correspondence to: Han Kyoung Cho
E-mail: trpchk@hanmail.net
ORCID: https://orcid.org/0000-0001-6074-013X
Received: January 15, 2024; Accepted: January 26, 2024; Published online: March 30, 2024.
© Korean Society for Laser Medicine and Surgery. All rights reserved.

This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Rosacea is a chronic inflammatory condition characterized by recurrent episodes of flushing, persistent erythema, inflammatory papules, pustules, and telangiectasia that usually affects the centrofacial region. Conventional oral and topical agents primarily target inflammatory papules and pustules, but limited evidence supports their ability to manage background facial erythema and telangiectasia. Instead, recommendations favor intense pulsed light (IPL) or vascular lasers, such as the pulsed dye laser (PDL), for treating erythematotelangiectatic rosacea (ETR). Previous studies have confirmed the effectiveness of PDL and IPL as treatments for facial erythema and telangiectasia. This report details the case of a 66-year-old Korean female with ETR successfully treated with IPL and highlights its potential as an alternative treatment option for ETR patients refractory to PDL and conventional medications.
Keywords: Erythematotelangiectatic rosacea; Intense pulsed light therapy; Pulsed dye lasers; Rosacea
INTRODUCTION

Rosacea is a chronic inflammatory disease primarily affecting the centrofacial region and eyes, marked by recurrent episodes of flushing, persistent erythema, inflammatory papules and pustules, and telangiectasia [1-3]. This condition can significantly impact personal appearance, leading to low self-esteem and adversely affecting quality of life, as well as social and psychological well-being [2,3]. Although the pathophysiology of rosacea is not fully understood, it is believed that an impaired skin barrier may trigger the release of various cytokines, ultimately leading to cutaneous inflammation [3,4]. Flushing and erythema indicate an increase in erythrocytes within the inflamed vasculature, while telangiectasia results from reduced integrity of dermal connective tissue and the degradation of collagen in capillary walls due to inflammation [4].

Intense pulsed light (IPL) emits light at a wavelength of 500-1,200 nm and can selectively destroy tissues based on the absorption spectra of the tissue. By using lower-cutoff filters (560 nm), IPL can target superficial small vasculatures, offering benefits in reducing background facial erythema and telangiectasia [1]. In this report, we present the case of a Korean female patient with rosacea who achieved successful treatment with IPL.

A written informed consent was obtained from the patient for the publication of this case report.

CASE REPORT

A 66-year-old female visited our clinic with diffuse erythema and telangiectasia on both cheeks and forehead that had begun six years ago and worsened three years ago (Fig. 1). She had no other relevant medical or family history. The patient had taken no medications except for painkillers and muscle relaxants (meloxicam 7.5 mg, eperisone 75 mg) after shoulder surgery two months prior. She underwent treatment with a pulsed dye laser (PDL, Vbeam® Prima; Candela) using laser parameters of fluence 9 J/cm2, spot size 7 mm, and pulse duration 6 ms. Additionally, she started taking minocycline 200 mg per day and using topical 0.75% metronidazole.

Figure 1. (A, B) Clinical photographs of the patient before treatment, showing diffuse erythema and telangiectasia on both cheeks and forehead.

Four weeks after the initial visit, the patient exhibited minimal improvement in erythema but expressed dissatisfaction. Consequently, she underwent treatment with IPL (broadband light, Joule®; Sciton), undergoing a total of three laser treatment sessions with a 4-week interval. The treatment protocol was as follows: initially, a 560 nm filter was used to scan the entire face, performing two passes with a fluence of 8 J/cm2, pulse duration of 15 ms, spot size of 1.5 × 4.5 cm2, and a cooling crystal temperature of 15°C. Subsequently, a 560 nm filter with a fluence of 13 J/cm2, pulse duration of 20 ms, spot size of 1.5 × 4.5 cm2, and a cooling crystal temperature of 20°C was employed. The patient kept taking oral minocycline for the total of nine weeks and then discontinued. Following the final session, the erythema and telangiectasia had completely resolved (Fig. 2). The patient kept using topical metronidazole after the last treatment and at the two months follow-up, there was no sign of recurrence.

Figure 2. (A, B) Clinical photographs of the patients after the last treatment session, demonstrating complete resolution of facial erythema and telangiectasia.
DISCUSSION

Traditional topical agents for rosacea, including azelaic acid, ivermectin, and metronidazole, as well as oral agents such as doxycycline and isotretinoin, are recommended for the treatment of inflammatory papules and pustules associated with rosacea [5,6]. Topical alpha-adrenergic agents and oral beta-blockers were previously used to treat erythematotelangiectatic rosacea (ETR) [6]. However, these options were excluded from the 2019 ROSacea COnsensus panel recommendations due to insufficient evidence. Instead, the updated recommendations now include IPL and vascular lasers as treatment options [5]. Lasers and other light devices have been effectively employed in treating various vascular lesions through the principle of selective photothermolysis. In this process, oxyhemoglobin, the target chromophore, absorbs light energy from a laser, converting it into thermal energy. This conversion leads to microvascular damage through photocoagulation and mechanical injury [7].

PDL is the most employed device for treating vascular lesions [7,8]. In its early iterations, the PDL emitted a pulsed beam of light ranging from 585 to 595 nm with a pulse duration spanning 0.45 to 1.50 ms. Unfortunately, these settings proved intolerable to patients due to side effects such as purpura, hyperpigmentation, crusting, and scarring [2,7,8]. In response to these challenges, recent advancements in PDL technology include longer pulse durations and the incorporation of an epidermal cooling system. This cooling system serves a dual purpose: enabling the application of higher fluences while safeguarding the epidermis. Consequently, these modifications facilitate a slower and gentler administration of thermal energy, thereby minimizing the impact on capillary walls and reducing post-treatment purpura [7,8].

IPL generates a noncoherent light beam with wavelengths ranging from 500 to 1,200 nm. Different filter settings enable the selection of a wide range of vessel colors in the vascular system [7]. Moreover, IPL can deliver single or multiple pulses of various durations, making it a versatile modality for treating different vascular lesions [2,7,8]. Additionally, IPL is widely employed to enhance facial skin photodamage, addressing issues like wrinkles, coarseness, laxity, and dyspigmentation by promoting the synthesis of collagen and elastic fibers. In the context of rosacea, the mechanical integrity of the upper dermal connective tissue diminishes, resulting in vessel dilatation and extravascular leakage of inflammatory mediators. Consequently, IPL can alleviate rosacea by eliminating abnormal vessels and restoring the connective tissue barrier through collagen remodeling [2].

Previous studies have compared the effectiveness of IPL and PDL in treating ETR. In a split-face trial conducted by Neuhaus et al. [8], both PDL and IPL demonstrated significant reductions in cutaneous erythema, telangiectasia, and patient-reported associated symptoms; however, no statistical differences were observed between these two modalities. Notably, no side effects were reported with either device [8]. In a similar vein, Handler et al. [9] conducted a split-face study using PDL and IPL, with both devices showing comparable efficacy and safety in reducing facial erythema. The specific parameters utilized in each study are summarized in Table 1.

Table 1 . Specific parameters used in previous split-face studies comparing efficacy of IPL and PDL

ReferencePDLIPL
Neuhaus et al. [8]
No. of patients22
Treatment protocol3 sessions with an interval of 4 weeks
Wavelength (nm)595560
Pulse duration (ms)6.02.4-6.0
Fluence (J/cm2)725
ResultsDecrease in spectrophotometric erythema scores on medial cheek (p = 0.05), blinded investigator score on erythema and telangiectasia (both p < 0.01), and patient visual analog scales on erythema, flushing, dryness, and pruritus (all p < 0.05) at visit 4 (1 month after the last treatment)Decrease in spectrophotometric erythema scores on medial cheek (p < 0.05), blinded investigator score on erythema and telangiectasia (both p < 0.01), and patient visual analog scales on erythema, flushing, dryness, and pruritus (all p < 0.05) at visit 4 (1 month after the last treatment)
Handler et al. [9]
No. of patients15
Treatment protocol2 sessions with an interval of 30 days
Wavelength (nm)595560
Pulse duration (ms)3030
Fluence (J/cm2)720
ResultsInvestigator ratings of change in erythema decreased from 3.2 (baseline) to 2.47 at day 90 (p < 0.01)Investigator ratings of change in erythema decreased from 3.2 (baseline) to 2.13 at day 90 (p < 0.01)

IPL, intense pulsed light; PDL, pulsed dye laser.



In the present study, the patient underwent initial treatment with PDL, yielding minimal effects. Consequently, we transitioned to IPL, successfully addressing facial erythema and telangiectasia, resulting in high patient satisfaction. This case underscores the potential of IPL as an alternative treatment for PDL-refractory ETR.

SUPPLEMENTARY MATERIALS

None.

ACKNOWLEDGMENTS

None.

AUTHOR CONTRIBUTIONS

Conceptualization: SJL. Resources: SJL. Project administration: SJL, HKC. Visualization: SJL, JL. Supervision: SJL, HKC. Writing–original draft: JL. Writing–review & editing: all authors.

CONFLICT OF INTEREST

No potential conflict of interest relevant to this article was reported.

FUNDING

None.

DATA AVAILABILITY

None.

References
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