The tiny superficial vessels of rosacea are very similar to the capillaries that make up port-wine birthmarks (capillary malformations), and the best treatment for both is pulsed dye laser. The wavelength (585nm) is highly absorbed by oxyhemoglobin, and the pulse duration (450 microseconds) at the appropriate energy is selected to match the thermal relaxation times of the target vessels. In other words, this laser was designed to treat exactly these close-to-the-surface tiny capillaries with out damaging normal tissues or deeper vessels. Port-wine stain vessels are more dense and layered in the upper layers of the skin (like cooked spaghetti noodles), whereas rosacea vessels are fewer and less "tangled," more like a lacy network of vessels. This means that red or pink birthmarks may take multiple treatments for maximum lightening, but most rosacea vessels respond quite nicely with a single (proper energy and skilled treatment technique) pulsed dye laser treatment (depending on the severity and degree of redness any individual rosacea patient).Each pulse of the laser is extremely short (about half of a thousandth or a second) but extremely high energy, and feels like a spatter of hot grease from a frying pan. (Too many doctors told their patients for years that a pulse from this laser felt like a rubber band snap on the skin. They must have never tried a test shot of the laser on their own skin--it's darn uncomfortable!) And since each spot is only 5,7, or 10mm in diameter, it takes several hundred pulses to treat an entire facial rosacea area. So, IV sedation is recommended. 25 years ago I treated my patients with this laser using only oral Valium and IM Demerol. Children were anesthetized. For my patients undergoing pulsed dye laser treatment today, I recommend IV sedation using Remifentanyl (a very short-acting strong narcotic) and Versed (a short acting sedative, relaxant, and amnesiac).The major downside to pulsed dye laser treatment is dark blue-black or purple bruising that occurs immediately during treatment. This is because the laser energy destroys the unwanted vessels by essentially "bursting" the vessel. The laser energy is selectively absorbed by the blood in the vessel, which is heated up by this energy in the fraction of a second of exposure, causing the vessel to rupture beneath the surface of the skin, and then "turning off" the laser energy (because of the short pulse duration) before there is heat damage to surrounding structures. Occasionally, the surface of the skin can develop a tiny blister, but careful energy selection and precise beam overlap will minimize these effects (and is why an experienced laser surgeon should be selected to perform this treatment, not just someone who has access to a pulsed dye laser).The bruise is not unlike a black eye, and reabsorbs over 7-10 days. A well-performed treatment will have no blistering, and cover make-up can be used, but heavy Covermark or DermaBlend make-ups that are required until the bruising is gone. But once gone, the vessels are truly obliterated, and since the laser energy does not go any deeper than the unwanted vessels, the skin remains perfectly normal in texture, pores, and now has its normal (non-red) color. One treatment is usually all that is required, and new rosacea vessels will take years to return (since the laser treatment doesn't "cure" rosacea, only treats the secondary vessels that develop). It works, and it's well worth it.IPL (intense pulsed light) or BBL (broad band light) treatments work similar to the laser, but essentially throw ALL the wavelengths of visible light at the unwanted vessels. This means that while the "proper" wavelengths for hemoglobin absorption are present in IPL or BBL energy, so are ALL of the unneeded wavelengths. This means more heat, more potential for damage to the skin, and therefore the need to use less energy overall. Your practitioner used a "safe" but ineffective energy setting. Unfortunately, sometimes an effective energy setting also means that there will be skin thermal damage at the same time as vessel thermal damage. That leaves a potential for scarring, which is why your practitioner was cautious, but also why the treatments were ineffective. Appropriate response to (well-performed) IPL should be seen in one or two treatments.I'd suggest selecting a Plastic Surgeon or Dermatologist skilled and experienced in pulsed dye laser treatment. Here's why: your IPL practitioner is probably as frustrated as you are. "One more time, but THIS TIME I'll crank up the energy and get those vessels." Perhaps; but perhaps burns and scarring. I've seen it.So use the laser that was custom-designed for vessels just like the ones you want to get rid of--Pulsed dye laser. V-beam is another alternative, but has longer shutter times, and therefore more thermal input, and slightly higher risk of blistering. I use pulsed dye laser for all of my rosacea patients because the parameters are precisely what those vessels require. Depending on size of the area to be treated, cost is $1500-2000 TOTAL. I hope this helps. Best wishes! Dr. Tholen
