|Year : 2021 | Volume
| Issue : 2 | Page : 111-119
Evaluation of the effectiveness of neodymium laser therapies for Rosacea of the face
Gagik Hakobyan1, Zoya Evsyukova2, Elena Ribakova3, Armen Haruthyunyan4, Nane Hovsepyan5
1 Department of Oral and Maxillofacial Surgery, Yerevan State Medical University after M. Heratsi, Yerevan, Armenia
2 University Clinic of the Russian State Social University, Moscow, Russia
3 Esthetic Centre Renew, Renew Premium Moscow, Moscow, Russia
4 Department of Oral and Maxillofacial Surgery, Astkhik Medical Center, Yerevan State Medical University after M. Heratsi, Yerevan, Armenia
5 Medical Centre Medbalans, Yerevan, Armenia
|Date of Submission||08-Jan-2021|
|Date of Acceptance||12-Feb-2021|
|Date of Web Publication||02-Jun-2021|
Prof. Gagik Hakobyan
Department of Oral and Maxillofacial Surgery, Yerevan State Medical University after M. Heratsi, 0028 Kievyan str. 10 ap. 65 Yerevan.
Source of Support: None, Conflict of Interest: None
Objectives: The study aimed at assessing the efficacy of neodymium laser therapies and Accutane (isotretinoin) systemic therapy for patients with rosacea. Materials and Methods: A total of 64 patients with rosacea were selected for the study for the treatment of facial rosacea; the study was conducted from 2016 to 2020. All patients underwent a thorough clinical examination according to the generally accepted scheme. Patients received neodymium laser therapies and Accutane (isotretinoin) systemic therapy. Investigator Global Assessment (IGA) scale, Laser Doppler Fluorometry (LDF), and Dermatology Life Quality Index (DLQI) questionnaire were used to assess outcome treatments, resulting in the rosacea of the scene before and after neodymium therapy and Accutane (isotretinoin) systemic therapy. Results: A multitargeted therapy effectiveness rosacea neodymium is ideal for the management of the signs and symptoms of rosacea and it results in reductions in the mean acne lesion counts after 7 seans therapy, with persistent reduction at the 12-month follow-up, indicating significant long-term remission. The average rosacea IGA scale decreased from 4.2 at baseline to 0.6 after treatment. The average indicators of DLQI before and after laser treatment were 17.3 and 2, 4 respectively. Laser Doppler imaging showed that the mean value of the facial area was 151 units, before treatment; after the treatment, the values decreased, and the mean was 129 units. Conclusion: Neodymium laser therapy exposure has been effective in treatment therapies for rosacea. Our results indicate that the use of neodymium monotherapy represents an option to consider when dealing with treatment rosacea, being effective, well tolerated, and free of side effects, as confirmed by clinical and instrumental evaluation. The condition improved from baseline in 92.3% of subjects.
Keywords: Accutane (isotretinoin), neodymium laser therapies, rosacea of the face
|How to cite this article:|
Hakobyan G, Evsyukova Z, Ribakova E, Haruthyunyan A, Hovsepyan N. Evaluation of the effectiveness of neodymium laser therapies for Rosacea of the face. MGM J Med Sci 2021;8:111-9
|How to cite this URL:|
Hakobyan G, Evsyukova Z, Ribakova E, Haruthyunyan A, Hovsepyan N. Evaluation of the effectiveness of neodymium laser therapies for Rosacea of the face. MGM J Med Sci [serial online] 2021 [cited 2021 Sep 20];8:111-9. Available from: http://www.mgmjms.com/text.asp?2021/8/2/111/317454
| Introduction|| |
Rosacea (syn Rosacea, redheads, acne rosacea, gutta rosacea, rosacea, facial telangiectasia) is a common skin disease that develops as a result of chronic recurrent lesions of the facial skin vessels (angioneurosis in the trigeminal nerve innervation zone)., This is a complex, multifactorial, chronic, and therapy-resistant disease. In these studies, foreign authors focus on violations in the system of “innate immunity,” which mostly affect the central face, with women being more affected than men. The pathophysiology of rosacea is not fully understood, but dysregulation of the immune system has been identified, as well as changes in the nervous and vascular systems. Pathophysiological diseases are complex; however, they are based on vascular disorders, which are manifested in increased reactivity of the vessels of the skin of the face, as well as in the redistribution of blood flow and its slowdown, into a further passing stasis in region v. Facialis and v. Angular. Vascular endothelial growth factor (VEGF) plays a great role in the pathogenesis of rosacea. Keratinocytes produce VEGF under the influence of proinflammatory cytokines; they interact with blood vessel endothelial receptors, enhancing vasodilation and their permeability, which leads to a persistent blood condition skin of the face and a subjective burning sensation and tingling sensation in patients.
The initial symptoms of rosacea are transient, beginning with a flush of capillary dilation and fleeting erythema; subsequently, telangiectasias develops and erythematous patches persist, especially on the cheeks and nose, followed by persistent erythema due to multiple vasodilatations; and finally, telangiectasia and skin inflammation in the form of papules, pustules, lymphedema, and fibrosis.
Trigger mechanisms are very diverse but they are divided into two groups: exogenous and endogenous. The cause of circulatory disorders is that they are subject to disorders associated with the connective tissue skeleton of the dermis, which leads to passive vasodilation and blood stasis in them, overfilling with temperature, topical irritants, and topical corticosteroids.,,,, The second is the colonization of the tick-borne Demodex genus in stomata with mucous-hair follicles, as well as due to a large number of porphyrites in sebum, the hemostatic system, hormonal imbalance of menopause, and the presence of H. Pylori and its associated diseases (Helicobacter stimulates diseases).,,
The diagnosis of rosacea is based on the clinical symptoms of the visible assessment and the patient’s medical history, after excluding other causes of facial erythema and/ or papulopustular skin lesions 2, 5, including contact dermatitis, seborrheic dermatitis, photodamage, acne vulgaris, cutaneous lupus, and carcinoid syndrome.,
The rosacea classification previously used subtype designations, as described by Wilkin et al. Current guidelines from several organizations that are interested in the diagnosis and treatment of rosacea suggest characterizing patients with rosacea for specific clinical presentations and symptoms that are present at the time of examination.
In the same patient at different time points, manifestations may differ depending on rosacea flare-up or silence, the age of the patient, the duration of his or her illness, the frequency and magnitude of rosacea flare-ups, and associated symptoms. The pathophysiological mechanisms that act in rosacea have been well documented in the literature.,
Skin microcirculation plays an important role in skin diseases such as rosacea. LDF is a noninvasive technique that monitors microvascular blood flow, which is a very important marker of skin tissue health. The method for determining LDF makes it possible to determine the values of microcirculation in various areas of healthy facial skin. It was found that the change in the LDF signal directly depends on the structural features of the structure of microvessels, the depth, and the density of functioning capillaries.,
Rosacea therapy is more symptomatic since the pathogenesis of diseases is complex and is represented by an imbalance of regulatory peptides of the microvasculature. Because the condition is chronic, treatment should be directed at controlling the frequency and severity of flare-ups. Management often requires medical treatment in the form of local antifungal agents, keratolytics, corticosteroids, and calcineurin inhibitors.
Currently, the main treatment methods are as follows: low-dose isotretinoin (minimum doses of Isotretinoin), antibacterial and anti-inflammatory (doxycycline, metronidazole), and sedative therapy (Bellataminal), extracts of ginkgo Biloba, horse chestnut, vitamin C, topical calcineurin inhibitors (Pimecrolimus), Azelaic acid gel, topical Ivermectin.,,,,,,,,,,,,,
One such method involves physical modalities for the treatment of rosacea. Among the physical treatments for rosacea, medical lasers are widely used., Medical lasers serve as the door to this cutting-edge technology that facilitates a variety of clinical and therapeutic applications. Being faster and less invasive with high precision, lasers have penetrated most medical disciplines during the past half-century, including dermatology, ophthalmology, dentistry, otolaryngology, gastroenterology, gynecology, cardiology, neurosurgery, and orthopedics.,,,,,,,
Laser therapy has changed the paradigm of rosacea treatment. The lasers commonly used include pulsed dye laser [PDL, 585–595 nanometer (nm)], intense pulsed light (IPL, 500–1200nm), potassium-titanyl phosphate (KTP, 532nm) laser, long-pulse neodymium:yttrium-aluminum-garnet laser (Nd:YAG, 1064nm), carbon dioxide (CO2), and erbium:yttrium-aluminum-garnet (Er:YAG). At present, we use highly specialized lasers as the flashlamp-pumped dye laser or less specific, more coagulative lasers as the KTP-, diode, or Nd: YAG-laser with either pulsed or continuous emission. Nd: YAG laser is one of the most recent surgical instruments to be exploited by dermatologists. Pulsed dye lasers and long-pulsed 532nm Nd: YAG lasers can do an excellent job of eliminating vascular ectasia and telangiectasia.
The mechanism of work-vascular coagulation occurs, and the laser effect on the tissue should last less than thermal relaxation of the vessel, to avoid heat loss and going beyond the vessel.,
The novel methods for facial rosacea are a welcome addition to the treatment armamentarium of the dermatologist. The study aimed at assessing the efficacy of neodymium laser therapies for rosacea of the face.
| Materials and methods|| |
A total of 64 patients with rosacea were selected for the treatment of facial rosacea that was conducted from 2016 to 2020. At the university clinic in the Department of Dermatology and Cosmetology of SSMU, YSMU treats patients with various forms of rosacea.
The study was reviewed and approved by the Ethics Committee of the Yerevan State Medical University after M. Heratsi (protocol No. 16,5.10.2017) and by those of the World Medical Association and the Helsinki Declaration. Patients were informed verbally and in writing about the study and they gave written informed consent.
All patients underwent a thorough clinical examination according to the generally accepted scheme. Clinical data included demographic and clinical variables: (1) gender, (2) age, and (3) type. The ages of the patients ranged between 27 and 62 years (23 males and 41 females); 28 patients had erythematotelangiectatic-type rosacea (9 males and 14 females); and 36 patients had papulopustular-type rosacea (18 males and 23 females).
Treatment planning includes a thorough history and physical examination, as well as a preoperative laboratory examination. All patients presented functional and aesthetic complaints. All patients underwent a thorough clinical laboratory examination according to a generally accepted scheme.
The patients were treated with a neodymium wavelength of 1064nm, neodymium laser (64–159 J/cm2) with a pulse frequency of 650 μs while taking Isotretinoin in minimal doses of 7 seans therapy. All patients signed a document informing them of Isotretinoin risks. The treatment regimen consisted of Isotretinoin, fixed 20mg daily, and the duration of treatment was based on the weight of the patient until a total cumulative dose of 120mg/kg of body weight was achieved. Isotretinoin is intended for the treatment of rosacea that is not responsive to other treatments. No topical or other systemic therapy was allowed during the trial. The protocol of treatment for rosacea neodymium therapy is presented in [Table 1].
The outcome was the evolution of the IGA scale, assessing erythema, several inflammatory lesions such as papules and pustules, all measured on a five-point scale, from 0: no signs/symptoms to 4:very severe signs/symptoms. Subjects were assessed at baseline after four weeks. The LDF has been used to assess microcirculation and treatment results of the rosacea of the scene before, during, and after neodymium monotherapy.,,
To assess the effect of laser on the quality of life of patients, for monitoring the effectiveness of therapy and patient satisfaction, all patients completed a DLQI questionnaire before and after three sessions of laser treatment. The DLQI is a validated questionnaire for evaluation of the quality of life of patients having dermatology issues, and it comprises 10 questions. The 10 questions of the DLQI can be grouped by using the following six headings: symptoms and feelings, daily activities, leisure, work and school, personal relationships, and treatment. The score is from 0 (without any effect on the quality of life) to 30 (worst effect on the quality of life).,,
Statistical analyses were performed by using SPSS software ver.22.0 (IBM, Armonk, NY, USA), and Med Calcprogram for Windows. To test the significance of variations in the BOP, PPD, and MBL, the t-test was used. The minimum level of statistical significance was set at a value of less than 0.05.
| Results|| |
During the process of working with the patient, it was found that a relatively low-energy flux density for a neodymium laser (64–96 J/cm2), with a pulse frequency of 650 μs, leads to accelerated maturation of deep infiltrates—foci of chronic inflammation with acne and rosacea. This also significantly improved microcirculation and, as a result, regression of chronic edema of the dermis. As a result of processing the entire area of the skin of the face, a regression of all elements of the pink brain occurs: various erythema, papules, empty, subcutaneous nodes (infiltrates), and a brush. However, they receive all the necessary fluids and also fluids with a higher density (127–159 J/cm2); there is a “pronounced clinical value” after the first procedure. Thus, a reasonable sign of treatment for most chronic inflammatory diseases is a wavelength of 1064nm.
The impact of the focused beam on the absorption spectrum of hemoglobin leads to the fact that it is exposed to juice (those and the walls, and the center), its coagulation, and low energy level (below 180 J/cm2), which can be used in the absence of such an effect and that does not lead to inappropriate overheating of surrounding tissues.
A multi-targeted therapy involving the effective rosacea neodymium laser is ideal for the management of the signs and symptoms of rosacea and results in reductions in the mean acne lesion counts after 7 seans therapy, with persistent reduction at the 12-month follow-up indicating significant long-term remission.
The average rosacea IGA scale decreased from 4.2 at baseline to 0.6 after treatment.
The average indicators of the DLQI before and after laser treatment were 17.3 and 2, 4, respectively. All patients experienced statistically significant improvements in quality of life (P < 0.0001, paired t-test). As laser Doppler imaging shows, the mean perfusion value of the facial area was 151 units before treatment. During the treatment, the values decreased, and the mean perfusion of the facial area was 129 units. This result suggested that the treatment might be effective in treating rosacea through blood redistribution and micro-circulation of the local skin area [Table 2]. A good correlation was found between clinical and instrumental evaluations [Figure 1][Figure 2][Figure 3][Figure 4].
|Table 2: Treatment results in the rosacea of the scene before and after neodymium monotherapy|
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|Figure 1: (A) Mild rosacea with papules and pustules cheeks before the treatment with Nd: YAG laser. (B) After two sessions, a significant reduction of rosacea was detected|
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|Figure 2: (A)Mild rosacea on cheeks before the treatment with neodymium laser. (B) After 7 rosacea disappeared|
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|Figure 3: (A) Papules and postuleos of rosacea before the treatment with neodymium laser. (B) After only one session, a significant reduction of rosacea was detected|
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|Figure 4: Erythema rosacea before the treatment with neodymium laser. B) After only two sessions, a significant reduction of rosacea was detected|
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| Discussion|| |
Rosacea is multifactorial, which can lead to scarring of the skin as well as psychological stress and low self-esteem, and it is difficult to control with standard pharmacological agents. Rosacea has genetic risk factors, including a genome-wide association signal in polymorphisms near the BPTK316 as well as signals in the MHC class II molecules.
It is assumed that neutrophils play an important role in the pathogenesis of rosacea. T cells (especially Th1/Th17 polarized immune cells), macrophages, mast cells, and neutrophils are present in all rosacea. Reactive oxygen species (ROS) and other proteases are produced by neutrophils and damage blood vessels, which causes inflammation as well as angiogenesis, which subsequently leads to telangiectasia.
Rosacea is usually symmetrically distributed over the face; is particularly obvious over the nose, cheeks, chin, forehead, and glabella; and is grouped into four main subtypes: erythematotelangiectatic, papulopustular, phymatous, and ocular as well as one variant, granulomatous rosacea.
Rosacea treatments are constantly evolving, and new options are becoming available. According to the literature, most topical or oral rosacea treatments are ineffective and have side effects whereas laser treatments are convenient, safe, and effective. Common therapies often include a topical steroid, which can have untoward effects, such as atrophy, telangiectasias, acne, and perioral dermatitis. Traditional antibiotic and retinoid therapy for rosacea has mixed results and may be complicated by antibiotic resistance and adverse treatment profiles.,[64-67]
New therapies have been developed to treat rosacea, such as laser therapy. Treatment with lasers may offer improvements in inflammatory rosacea and rosacea scarring, with more limited benefit for noninflammatory (comedonal) acne. Laser treatment has revolutionized the treatment of erythematotelangiectatic rosacea, which is unresponsive to other treatments.
Published studies have evaluated IPL, pulsed dye laser, and nonpurpura genic pulsed dye laser, and, in general, they have shown a reduction in facial redness, a decrease in telangiectasias.,,In complex rosacea therapy, a laser is increasingly used, especially to combat generalized erythema, hyperemia, and telangiectasias. Typically, three or more treatments are given in four- to six-week intervals. Lasers harness wavelengths of powerful light in short bursts (which creates heat) to destroy blood vessels without harming the surrounding tissue.
The use of a laser to treat rosacea is gradually gaining in popularity as these methods are safe, effective, and with minimal complications when used correctly. Lasers are also used in combination with pharmacological agents to synergize their effects and optimize therapeutic outcomes. For erythematous lesions and telangiectasias, IPL therapy and lasers are popular treatment options. For papulopustular rosacea, topical antibiotics, topical and systemic retinoids, and systemic antibiotics are used. Ablative laser treatment has largely supplanted classical abrasive tools. Light absorption leads to photo-excitation of porphyrins and subsequent release of singlet oxygen and reactive-free radicals that exert bactericidal effects on P.acnes. Longer wavelengths, such as red light, activate porphyrins less effectively but penetrate deeper into the skin, where they may directly target sebaceous glands and exert anti-inflammatory properties by influencing cytokine release from macrophages.,,,
A limited number of studies examined lasers compared with or in combination with conventional rosacea therapy. Shariff et al. reported the safety and efficacy of laser therapy in combination with multiple treatments in a patient with rosacea and history of comorbidities, which contraindicated the use of most traditional first-line treatments.
A study of 35 patients with moderate to severe acne treated with 1320nm Nd: YAG laser therapy showed a 57% reduction in inflammatory lesions and a 35% reduction in non-inflammatory lesions. In a study without a control group, 19 patients with inflammatory facial acne were treated with a 1450nm diode laser at four- and six-week intervals.
The goal of treatment for rosacea should be to provide safe and effective treatment that improves symptoms, reduces recurrence, and causes minimal side effects. Topical steroids and calcineurin inhibitors reduce inflammation. Although these treatments have been demonstrated to be effective, the need for long-term treatment can cause side effects and cosmetic problems that may limit their use. In these cases, the use of topical nonpharmacological therapies may be considered.
Nonpharmacological treatments include laser and light therapies and medical devices. Both fluences (14 or 16 J/cm2) resulted in reductions in the mean acne lesion counts after one and three treatments, with a persistent reduction of 70.5%–76.1% at the 12-month follow-up, indicating significant long-term remission. In contrast, the combination of microdermabrasion plus 1450nm laser (55.6% reduction in acne lesions) was not significantly different from 1450nm laser alone (53.5% reduction in acne lesion) in inflammatory facial acne clearance.,
Glaich et al. studied the combined use of 595nm PDL and 1450nm IR diode laser in 15 patients with inflammatory facial acne and found significant mean reductions of 52%, 63%, and 84% in lesions after one, two, and three treatments, respectively. This demonstrated the use of combination lasers as a safe and effective treatment for inflammatory facial acne, acne scars, and post-inflammatory erythema. However, the effect of PDL alone or 1450nm diode laser has not been determined. This demonstrated the use of combination lasers as a safe and effective modality for the treatment of inflammatory facial acne, acne scarring, and post-inflammatory erythema. However, the effects of the PDL or the 1450nm diode laser used alone are undetermined.
Different laser therapies that target the vessels have been used, such as 595nm pulsed dye laser, Nd: YAG and other vascular lasers, or IPL therapy. These should be administered by an experienced and trained laser therapist, and the number of sessions and length of treatment varies for each individual.
This article focuses on laser therapy used to treat rosacea and discusses its uses, benefits, and efficacy; 28 patients had erythematotelangiectatic-type rosacea, and 36 patients had papulopustular-type rosacea.
The impact of a focused beam of neodymium laser on pathologically altered tissues leads to the restoration of microcirculation, as well as to the acceleration of the maturation and degeneration of endothelial tissue, on the one hand, and to the stimulation of the maturation of connective tissue on the other. Laser therapy, including neodymium laser, may help to reduce refractory background erythema and clinically significant telangiectases.
In this article, we present the patients treated with used neodymium laser therapy at a wavelength of 1064nm, neodymium laser (64–159 J/cm2) with a pulse frequency of 650 μs, while taking Isotretinoin in minimal doses. Our patients exhibited a significant and sustained improvement with the combined use of neodymium laser and Isotretinoin.
The use of either neodymium laser therapy significantly reduced the IGA score by 92,3% at four weeks.
The effectiveness of the treatment for rosacea in using this technique should be evaluated by using LDF, as the most affordable noninvasive nature of the study of blood flow in the skin. During the treatment, the perfusion values decreased. The mean value LDF of the facial area was 151 units before treatment. During the treatment, the values decreased, and the mean value LDF in the facial area was 129 units.
This result suggested that the treatment might be effective in treating rosacea through blood redistribution and microcirculation of the local skin area. For rosacea, LDF is an effective method for examining microcirculation disorders in the skin and affected skin, as well as for assessment.
Rosacea is a common inflammatory skin disorder that can seriously impair quality of life. The average indicators of the DLQI before and after laser treatment were 17.3 and 2.4, respectively.
The questionnaire for determining the quality of life index in dermatology (before and after laser treatment) is an important tool for evaluating the treatment of rosacea. The patients with rosacea are at increased risk of depression and anxiety and tend to avoid social situations. Effective treatment of clinical symptoms results in significant improvement in psychological symptoms.
The positive results in these cases suggest that this combined treatment modality may serve as an example of safe and effective treatment. Neodymium laser therapy should be administered by an experienced and trained laser therapist, and the number of sessions and length of treatment varies for each individual.
| Conclusion|| |
Neodymium laser therapy exposure has been effective in treatment therapies for rosacea. Our results indicate that the use of neodymium monotherapy represents an option to consider when dealing with treatment rosacea, being effective, well tolerated, and free of side effects, as confirmed by clinical and instrumental evaluation. The condition improved from baseline in 92.3% of subjects.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/ have given his/ her/ their consent for his/ her/ their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]