Microsoft word - verebelyi study.doc

Case Study: Comprehensive Treatment for Severe Rosacea
using Intense Pulse Light and a Novel Non-Ablative 1064Nd:YAG

David M. Verebelyi, M.D.
Medical Director, Azure Medical, Denver, CO
Historically, rosacea treatments consisted of To resolve current rosacea eruption, repair prescribing oral antibiotics, steroids, and all depths of vascular damage, and improve isotretinoin, focusing more on the immediate the fibrotic sequelea of the disease using a eruption of the disease rather than the lasting combination of oral antibiotics and light recently, Intense Pulse Light (IPL) has been shown to aid in the resolution of the vascular Method and Materials
telangiectasia and general erythema. To this A single patient with severe nodular rosacea point, no modality has effectively addressed was treated over a course of approximately 6 the fibrotic consequences of this disease process. This case study addresses a rosacea treatment using antibiotics, Intense Pulse course of the treatment. Patient results have continued to improve through the 6 month 1064Nd:YAG (Yttrium, Aluminum, Garnet)
lasting results than treatment from oral and Conclusion
Adding non-ablative, 1064Nd:YAG laser to IPL and antibiotics during the treatment of rosacea results in better overall cosmetic
There is no current consensus for the exact dermatology at the University of Muenster cause of rosacea. Although a significant increase in Demodex folliculorum has been found, the clinical significance of this is still endothelial cell function in rosacea skin. in question. This hair mite may clog oil PAR-2 can serve as a receptor for several glands in susceptible patients, leading to the molecules, including dust mite antigens and mite counts after one month of tetracycline difference even though acute eruptions have resolved3, 8. Helicobacter pylori have also been studied as a possible cause. However, characteristics of the disease. At its’ core, in a double blind controlled study on the disorder that blooms in the presence of both benefit on the overall rosacea assessment the right genetic factor and environmental score1, 9. Current research has focused more conditions. Treatment modalities that both on a genetic level. Dr. Martin Steinhoff and alter the vascular pathogenesis and are able to aid in the fibrotic sequelea, will be key site over the next seven to ten days13. Once there, these cells start depositing collagen into the treated area. Due to the overall Rosacea treatment has classically consisted flushing also occurs. This flushing gives the of topical and oral antibiotics with steroids IPL a larger target and better absorption at and isotretinoin reserved for resistant cases. topical treatment, there is only a 35% patient satisfaction rate12. In the last five years, thoroughly cleaned and photos are taken. A several studies have been done utilizing IPL 5mm spot size is selected on the handpiece. Initial starting parameters are: fluence telangiactatic matting that occur. In one study of 32 patients treated with IPL, 83% pulse/second frequency for Fitzpatrick skin experienced reduced redness, 75% said they types I-III. The handpiece is kept about 2cm had less flushing and improved skin texture, over the skin and continuously moved back and forth in an airbrushing motion. This continuous movement protects any one area quoted at less than 1% over a three year from thermal injury. Approximately 10,000- follow-up7. But adding IPL is not effective 12,000 pulses are used. 4,000 pulses are treatment for the deeper vascular damage done in each cheek with about 3,000 done and fibrotic sequelea of the disease. Fibrosis over the forehead. IPL immediately follows and elastosis can be significant even in mild disease. This report consists of one case procedures together take about 45 minutes to using antibiotics, Intense Pulse Light (IPL) and a novel non-ablative 1064Nd:YAG laser to achieve resolution of the acute eruption, Our patient is a 40 year-old female patient, telangiectasia, fibrosis and elastosis in a Fitzpatrick skin type II. She has a several patient with severe rosacea. This achieved superior, long lasting results from what rosacea. The patient was informed of the would be expected from antibiotic and IPL experimental nature of the treatment and questions about the procedure. Appropriate Patients and Methods
operative consents were signed. A thorough history and physical were then performed thick red plaques with pustules were noted (Cutera, Brisbane, CA). This laser works in over cheeks, forehead, upper lip and chin. two ways. The first is selective thermolysis. Significant fibrotic scarring was noted on both cheeks from previous episodes (Fig. 2). The patient’s face was thoroughly cleaned and pre-op photographs were taken using a selective thermolysis of vascular tissue in the papillary dermis, reaching vessels too deep to be addressed by the IPL. The second Lite MR-14EX. Appropriate eye protection collagenosis. The microsecond pulse creates before the treatment began. Laser Genesis a temperature increase of 5 o- 8 oC in the was performed over the entire face (Table 1) papillary dermis. This is enough to stimulate and then IPL was performed over the same cytokine release and bring fibroblast to the area (Table 2). No anesthesia was necessary. The patient rated the discomfort for the procedure a three out of a scale of ten. The patient started with Doxycycline 100mg po The most popular IPL’s tend to use short bid. After each of her treatments, a broad wavelengths, in the 500-600nm range. These shorter wavelengths do not penetrate well dioxide was applied and appropriate after- into the papillary dermis and therefore are care instructions were given. Patient had not effective in dealing with deeper vascular interim pictures taken 2 weeks after the tissue. Histology would likely be beneficial process). The patient received a total of 5 Nd:YAG. To this point, only a handful of scattered studies have begun to investigate this. Preliminary work suggests that the approximately 4 weeks after last treatment. papillary or possibly into the deep dermis. It is also known that microsecond pulses from During a follow-up call 48 hours after the response that brings fibroblast into the area treated13. These lay down new collagen over pustules and redness. At four weeks, there collagen helps support existing vessels and thickness of the plaques had improved. By fills in scarring from previous eruptions. The the third treatment, most of the erythema scarring over both cheeks improved by 30- without a control group, this is difficult to Subjectively, the patient reported to be extremely happy with the results. Using a scale of one to ten (one being extremely pathology in different layers of the skin will satisfied) to measure the treatment and the improve outcomes. While IPL has advanced the level of patient satisfaction, there are still several aspects of the disease process that Discussion
are not well treated. These include deeper As collagen decreases with age and elastosis vascular lesions, fibrosis and elastosis. This worsens due to continuing UV exposure, the novel non-ablative Nd:YAG addresses these supporting structure of cutaneous vessels rosacea tends to show up in the third decade rosacea treatment both improving vascular and continues to worsen without treatment. Historically, antibiotics have been used with limited success, possibly functioning more Pulse duration
Date Fluence
* No IPL treatment done due to broken flash bulb
Fig. 1
Optical Absorption of Oxygenated and Deoxygenated Hemoglobin

1. Bamford JT, Tilden RL, Blankush JL, Gangeness DE. Effect of treatment of Helicobacter pylori infection on rosacea. Arch Dermatol 1999;35:659-63. 2. Ceilley RI. Advances in the topical treatment of acne and rosacea. J Drugs Dermatol Sep 3. Georgala S, Katoulis AC, Kylafis GD, Koumantaki-Mathioudaki E, Georgala S, Aroni K. Increased density of Demodex folliculorum and evidence of delayed hypersensitivity reaction in subjects with papulopustular rosacea. J Eur Acad Dermatol Venereol 2001;15:441-4. 4. Laube S, Lanigan SW. Laser treatment of rosacea. Journal of Cosmetic Dermatology 5. Mark KA, Sparacio RM, Voigt A, Marenus K, Sarnoff DS. Objective and Quantitative Improvement of Rosacea-Associated Erythema After Intense Pulsed Light Treatment. Dermatologic Surgery Jun 2003:29(6):600-4. 6. Rone M, Kisis J. IPL therapy in the inflammatory stage of rosacea. Journal of Cosmetic Dermatology 7. Schroeter CA, Haaf-von Below S, Neumann H. Effective Treatment of Rosacea Using Intense Pulsed Light Systems. Dermatologic Surgery Oct 2005: 31(10):1285-9. 8. Sibenge S, Gawkrodger DJ. Rosacea: a study of clinical patterns, blood flow, and the role of Demodex folliculorum. J Am Acad Dermatol 1992;26:590-3. 9. Son SW, Kim ICH, Oh CH, et al. The response of rosacea eradication of Helicobacter pylori. Br J 10. Steinhoff M, Neisius U, Ikoma A, Fartasch M, Heyer G, Skov PS, Luger TA, Schmelz M. Proteinase- Activated Receptor-2 Mediates Itch: A Novel Pathway for Pruritus in Human Skin. The Journal of Neuroscience Jul 2003;23(15):6176-6180. 11. Taub, AF. Treatment of rosacea with intense pulsed light. Journal of Drugs in Dermatology Jun 12. Wolf, John E. Efficacy and Safety of Once-Daily Metronidazole 1% Gel Compared to Twice-Daily Azelaic Acid 15% Gel in the Treatment of Rosacea. 64th Annual Meeting of the American Academy of Dermatology Mar 2006; poster #562. 13. Yeh A. Imaging wound healing using optical coherence tomography and multiphoton microscopy in an in vitro skin-equivalent tissue model. Journal of Biomedical Optics April 2004;9(2):248-253 2007, Cutera, Inc. All rights reserved. Cutera is a registered trademark and Laser Genesis is a trademark of Cutera, Inc. D0535 Rev A 0507


Literacy – Reading across the curriculum Foundation Phase Reception Foundation Phase Elements Learners are able to: Learners are able to: Learners are able to: Locating, • choose reading materials including books• choose reading materials and explain what the text is about and why they like it • choose reading materials independently giving reasons for the

Microsoft word - lic-bio-dftdex_1.doc

Clinical Biochemistry & Immunology Department Dynamic Function Tests Title: Low Dose Dexamethasone Suppression Test Master copy of this instruction resides on Q-pulse. Uncontrolled if in hard copy. Printed documents may become out of date – always check you are using the current revision. Principle Dexamethasone is a potent cortisol analogue. In normal patients, adminis

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