Long-pulsed dye laser vs. intense pulsed light for the treatment of facial telangiectasias: a randomized controlled trial

Efficacy, tolerance and acceptability of pulsed dye laser on facial and neckline telangiectasias in systemic scleroderma: a prospective open-label monocentric study in 21 patients

Facial and neckline telangiectasias have an underestimated yet important impact on quality of life of patients with systemic scleroderma (SSc). This monocentric, prospective, open-label, intra-patient comparative study was conducted in 21 consecutive patients with SSc. Patients underwent 4 sessions of PDL 8 weeks apart. A final quadruple assessment was performed by several raters 2 months after the last session, based on the following criteria: change in telangiectasia number; subjective improvement score (LINKERT scale); impact on the quality of life (QoL; SKINDEX score); visual analog pain scale; adverse effects (AEs), including treatment discontinuation for PDL-induced purpura and patient satisfaction. The mean telangiectasia number decreased by 5 (32%) at the end of the protocol. Eighteen patients (85.7%) reported an improvement or a strong improvement, versus 73.81% for the expert committee. Immediate session pain (mean = 3.4/10) was slightly less than overall pain (mean = 4.6/10). Ten patients (47%) experienced at least one AE (oozing/crusts, edema, epidermal blistering), including PDL-induced purpura in 3 patients (14%). AEs were mostly transient (<1 week) and mild (CTCAE grade 1). All QoL parameters improved after treatment, and 85% of patients were satisfied.

Light-based therapies in the management of rosacea: a systematic review with meta-analysis

BACKGROUND

The current scenario and position of laser and light-based therapies (LLBT) in the therapeutic rosacea scheme are lacking evidence-based recommendations and comparisons on efficacy and tolerability among different devices. This article aimed to systematically compare the efficacy, acceptability, and tolerability of the pulsed dye laser (PDL) versus other devices.

METHOD

A literature search was conducted in March 2020. Four domains were analyzed throughout the following six outcomes: Spectrophotometer erythema index and percentage of reduction for background erythema, telangiectasia grading scale for telangiectasias, visual analog scale for pain, and physician's assessment and patient's satisfaction for treatment success.

RESULTS

Our search yielded 423 potentially relevant studies. After removing the excluded and duplicated records, 12 records were assessed for eligibility in the meta-analysis. Erythema (RR:0.38 95%CI: -0.20-0.95), telangiectasias (RR:0.54 95%CI: -0.87-1.94), and the treatment success throughout the physician's assessment (RR:1.23 95%CI: 0.74-2.04) and the patient's satisfaction (RR:1.15 95%CI: 0.73-1.82) were not significantly different between pulsed dye laser and other LLBT. In the pain domain, PDL was as painful as other LLBT (RR:-0.23 95%CI: -0.96-0.49) but more painful than neodymium: yttrium-aluminum-garnet laser (RR:0.84 95%CI: 0.53-1.14) and less than intense pulsed light (RR:-1.18 95%CI: -1.56-0.80).

CONCLUSION

This work based on previously published literature demonstrates that the quality of evidence to support any recommendation on LLBT in rosacea is low-to-moderate. Among all the available devices, PDL holds the most robust evidence, although in the meta-analysis the effectiveness was comparable to other LLBT, such as neodymium: yttrium-aluminum-garnet laser (Nd-YAG) or IPL.

Retrospective Study of Factors Affecting Efficacy of Therapy with Dye Pulsed Light for Erythematotelangiectatic Rosacea

INTRODUCTION

Dye pulsed light (DPL) was proven to be effective at treating erythematous and telangiectatic skin disorders. However, there are limited data on the efficacy of DPL treatment for erythematotelangiectatic rosacea (ETR), and researchers do not fully understand the factors that may affect the efficacy. Here, we performed a study to investigate the efficacy of DPL treatment for ETR and determine the factors affecting that efficacy.

METHODS

Sixty-five patients with ETR underwent three treatment sessions with DPL at 4-week intervals and were followed up at 4 weeks after the last treatment session. Skin type, sex, age, lesion site, severity of erythema and telangiectasia, VISIA percentile ranking, clinical photographs and red area images were recorded at baseline. The post-treatment erythematous and telangiectatic scores and VISIA percentile rankings were recorded, and the effects of different personal and clinical factors on the efficacy were statistically analysed.

RESULTS

The erythema and telangiectasia scores and VISIA percentile rankings showed significant improvement after the DPL procedures (p < 0.01). With regard to erythema, treatment efficacy was not affected by any of the investigated variables, including pre-treatment erythema scores, skin type, pre-treatment VISIA percentile ranking, sex, age and lesion site (p > 0.05). With regard to telangiectasia, the treatment efficacy was greater for mild telangiectasia than for severe telangiectasia (odds ratio = 4.14, p < 0.05). There was no significant difference in treatment efficacy between the moderate and severe categories (odds ratio = 4.00, p > 0.05).

CONCLUSION

DPL is not the optimal procedure for treating severe telangiectasia in patients with ETR, whereas the efficacy of the treatment for erythema was not affected by the severity of the condition.

Interventions for rosacea based on the phenotype approach: an updated systematic review including GRADE assessments

BACKGROUND

Rosacea is a common chronic facial dermatosis. Classification of rosacea has evolved from subtyping to phenotyping.

OBJECTIVES

To update our systematic review on interventions for rosacea.

METHODS

We searched CENTRAL, MEDLINE, Embase, LILACS, Science Citation Index and ongoing trials registers (March 2018) for randomized controlled trials. Study selection, data extraction, risk-of-bias assessment and analyses were carried out independently by two authors. Grading of Recommendations, Assessment, Development and Evaluations (GRADE) was used to assess certainty of evidence.

RESULTS

We included 152 studies (46 were new), comprising 20 944 participants. Topical interventions included brimonidine, oxymetazoline, metronidazole, azelaic acid, ivermectin and other topical treatments. Systemic interventions included oral antibiotics, combinations with topical treatments or other systemic treatments. Several studies evaluated laser or light-based treatment. We present the most current evidence for rosacea management based on a phenotype-led approach.

CONCLUSIONS

For reducing temporarily persistent erythema there was high-certainty evidence for topical brimonidine and moderate certainty for topical oxymetazoline; for erythema and mainly telangiectasia there was low-to-moderate-certainty evidence for laser and intense pulsed light therapy. For reducing papules/pustules there was high-certainty evidence for topical azelaic acid and topical ivermectin; moderate-to-high-certainty evidence for doxycycline 40 mg modified release (MR) and isotretinoin; and moderate-certainty evidence for topical metronidazole, and topical minocycline and oral minocycline being equally effective as doxycycline 40 mg MR. There was low-certainty evidence for tetracycline and low-dose minocycline. For ocular rosacea, there was moderate-certainty evidence that oral omega-3 fatty acids were effective and low-certainty evidence for ciclosporin ophthalmic emulsion and doxycycline.

Successful treatment of facial vascular skin diseases with a 577-nm pro-yellow laser

BACKGROUND

Treatment of vascular skin diseases is one of the most important indications of the laser.

AIMS

To evaluate the effectiveness of 577-nm pro-yellow laser in the treatment of some vascular skin diseases.

PATIENTS/METHODS

Ninety-five patients with vascular skin diseases were included in this prospective monocentric study. They were classified into: port-wine stain birthmarks (n = 37), papulopustular rosacea (n = 20), facial telangiectasia (n = 16), and facial erythema (n = 22). All participants received a monthly session of 577-nm pro-yellow laser. Follow-up was done by comparing the photographs before and at every follow-up visit.

RESULTS

At the final visit, there was a significant improvement (>50%) occurred in 24/37 (64.82%), 12/20 (60%), 10/16 (62.5%), and 19/22 (86.3%) cases and poor response occurred in 6/37 (16.2%), 2/20 (10%), 2/16 (12.5%), and 0/22 cases after a mean number of sessions 7.76 ± 2.28, 3.1 ± 1.8, 3.63 ± 1.12, and 1.8 ± 0.85 in port-wine stain, rosacea-, facial telangiectasia-, and facial erythema-treated groups, respectively. Transient irritation and erythema during the session were the only complications reported in the study.

CONCLUSION

Facial port-wine stains, rosacea, telangiectasia, and erythema can be successfully treated with a single pass of 577-nm pro-yellow laser with a minimal side effect. Facial erythema showed the highest degree of success with the least number of sessions, while more sessions needed for the treatment of port-wine stain.

Topical brimonidine reduces IPL-induced erythema without affecting efficacy: A randomized controlled trial in patients with facial telangiectasias

BACKGROUND

Laser and intense pulsed light (IPL) are standard symptomatic treatments for superficial telangiectasias, but postoperative erythema, oedema, and pain may prolong downtime.

OBJECTIVES

To investigate whether topical brimonidine reduces IPL-induced inflammation in patients with moderate to severe facial telangiectasias.

METHODS

A randomized, two-centre, single-blinded, split-face trial on adjuvant brimonidine and air-cooling versus air-cooling alone (control) in 19 patients treated in Denmark (n = 10 patients) and Belgium (n = 9). Brimonidine was applied to the allocated side after each of three facial IPL-treatments, given at 3-week intervals. Patients were assessed up to 1 month after the final treatment. Outcome measures included blinded clinical on-site evaluation of erythema and oedema (5-point-scales), objective erythema-scores (red-filter analysis), patient-evaluated pain (Visual Analogue Scale), IPL-efficacy (blinded photo-evaluation of telangiectasia clearance), and patient preference.

RESULTS

In total, 19 patients were enrolled and completed the study. IPL induced moderate to severe erythema after each treatment. Application of brimonidine, reduced erythema to baseline values compared to air-cooling alone and sustained efficacy 24 hours after treatment (median difference reduction: score 1 at each assessment, P ≤ 0.022). Objective erythema-scores supported clinical findings, demonstrating a median erythema reduction of 50-95% after application of brimonidine and air-cooling compared to 9-28% reduction after air-cooling alone (P ≥ 0.002). No difference in reduction of IPL-induced oedema was observed between facial sides (P ≥ 0.227). Brimonidine and air-cooling slightly and consistently reduced postoperative pain compared to air-cooling alone (VAS 1.0 after brimonidine versus VAS 1.5-2.0 after air-cooling alone at treatment 1-3, P ≤ 0.032). At 1-month follow-up, patients experienced excellent clearance of telangiectasias (75-100% clearance) on both facial sides (P = 1.000). Patient preference supported clinical data and 79% of patients preferred brimonidine to control (P = 0.019).

CONCLUSION

Compared to air-cooling alone, adjuvant brimonidine reduces IPL-induced erythema and associated pain while maintaining a high IPL-efficacy. Lasers Surg. Med. 50:1002-1009, 2018. © 2018 Wiley Periodicals, Inc.

One-year follow-up of a TRASER clinical trial for the treatment of nasal telangiectasias

OBJECTIVES

To evaluate the long-term efficacy of treating nasal telangiectasias with the TRASER device.

METHODS

Subjects from the TRASER efficacy analysis clinical trial were invited for a 1-year follow-up. Standardized photographs were taken to compare to baseline. The same clinical trial evaluator graded the subjects' current vessel clearance using the 5-point telangiectasia scale. The data was compiled and analyzed.

RESULTS

Of the subjects with available follow-up data, 44% maintained "complete vessel clearance," 44% dropped down one grade to "almost complete vessel clearance," and 11% dropped down to "moderately clear vessel clearance." All showed clinically significant improvement in nasal telangiectasias from baseline.

CONCLUSIONS

The TRASER effectively treats nasal telangiectasias with minimal to mild recurrence at 1-year follow-up. Lasers Surg. Med. 50:61-63, 2018. © 2017 Wiley Periodicals, Inc.

Swiss S1 guideline for the treatment of rosacea

Rosacea (in German sometimes called 'Kupferfinne', in French 'Couperose' and in Italian 'Copparosa') is a chronic and frequently relapsing inflammatory skin disease primarily affecting the central areas of the face. Its geographic prevalence varies from 1% to 22%. The differential diagnosis is wide, and the treatment is sometimes difficult and varies by stage of rosacea. For erythematous lesions and telangiectasia, intense pulsed light (IPL) therapy and lasers are popular treatment option. In addition, a vasoconstrictor agent, brimonidine, has recently been developed. For papulopustular rosacea, topical antibiotics, topical and systemic retinoids, as well as systemic antibiotics are used. A topical acaricidal agent, ivermectin, has undergone clinical development and is now on the market. In the later stages, hyperplasia of the sebaceous glands develops, resulting in phymatous growths such as the frequently observed bulbous nose or rhinophyma. Ablative laser treatments have largely replaced classical abrasive tools. Here, we reviewed the current evidence on the treatment of rosacea, provide a guideline (S1 level) and discuss the differential diagnosis of rosacea.

Physical modalities for the treatment of rosacea

Rosacea is characterised by a wide variety of vascular changes. Apart from telangiectasia and erythema, often so-called flushing occurs. These vascular abnormalities can be targeted with specific light and laser devices. In addition to KTP laser, pulsed dye laser (PDL) and Nd:YAG laser, also intense pulsed light devices (IPLs) are used. The described therapeutic effects include the reduction of vascular abnormalities and even improvement of papulopustular changes. While the KTP laser shows very good results in telangiectasia, the dye laser and IPL devices are used preferably in erythema. The Nd:YAG laser is also a possibility for patients with telangiectasia and erythema. However, compared to the other laser and light devices the Nd:YAG laser carries the highest risk of unpredictable scarring. Phymatous changes are another clinical manifestation of rosacea, mostly affecting the nose (rhinophyma). Moderate and severe cases are commonly treated with ablation modalities. Traditional surgery is a treatment option, but is often associated with major intraoperative bleeding. Alternative methods include electrosurgery and dermabrasion, although both methods can cause scarring. Newer methods such as CO₂ laser ablation, possibly in combination with the erbium:YAG laser, are safe alternatives with a lower risk of complications.

Physikalische Methoden zur Behandlung der Rosazea

Die Rosazea ist durch vielfältige vaskuläre Veränderungen gekennzeichnet. Neben Teleangiektasien und Erythemen treten häufig auch sogenannte "Flushings" auf. Haupteinsatzgebiete von Licht- und Lasersystemen sind diese vaskulären Veränderungen, wie Erytheme und Teleangiektasien. Neben dem KTP-Laser, dem Farbstofflaser (PDL) und dem Nd:YAG-Laser kommen auch Blitzlampen (IPL) zum Einsatz. Neben der Rückbildung der vaskulären Komponente, ist auch eine Verbesserung der papulopustulösen Komponente beschrieben. Während der KTP-Laser sehr gute Ergebnisse bei Teleangiektasien zeigt, werden der Farbstofflaser und die Blitzlampen bevorzugt bei flächigen Erythemen eingesetzt. Der ND:YAG-Laser kann bei Teleangiektasien und Erythemen eingesetzt werden, birgt aber von allen Systemen das nicht einschätzbare Narbenbildungsrisiko in sich. Die Bildung von Phymen stellt eine klinische Ausprägung der Rosazea dar. Das am häufigsten vorkommende ist das Rhinophym. Bei moderaten und schweren Formen steht die Abtragung im Vordergrund. Die klassische chirurgische Abtragung stellt eine Möglichkeit zur Behandlung dar, häufig kommt es hierbei jedoch intraoperativ zu stärkeren Blutungen. Alternativmethode ist die Elektrochirurgie und die Dermabrasion, wobei bei beiden Methoden Narbenbildungen auftreten können. Neuere Methoden wie die CO₂ -Laserabtragung, eventuell in Kombination mit der Erbium:YAG-Abtragung, stellen sichere und komplikationsärmere Varianten dar.

Nd:YAG Laser Treatment for Extranasal Telangiectasias: A Retrospective Analysis of 38 Patients with Hereditary Hemorrhagic Telangiectasia and Review of the Literature

BACKGROUND/AIMS

Extranasal telangiectasias are common amongst hereditary hemorrhagic telangiectasia (HHT) patients. Telangiectasias can be found at sites like the external nose, lips, oral cavity and fingers. Although not life threatening, they can be annoying for patients and lead to bleeding in some cases, necessitating treatment.

METHODS

The data of 38 HHT patients treated for extranasal telangiectasias during a period of 10 years by means of Nd:YAG laser were retrospectively analyzed.

RESULTS

The telangiectasias treated affected predominantly the tongue, facial skin and lips. During a minimum follow-up of 3 years, only 7 patients required a revision of surgery.

CONCLUSION

This study shows that Nd:YAG laser constitutes a fast, safe and efficient therapeutic modality for the treatment of extranasal telangiectasias.

Rosacea: a Clinical Review

Rosacea is a field within dermatology with new insight within immunological research and new treatment-algorithm. Patient education on rosacea and appropriate treatments is an important aspect in helping patients succeed with therapy. Treatment should be tailored to each individual patient, taking into account: symptoms, trigger factors, patients' wishes, most bothersome symptoms, psychological aspect, individual needs. A combination of clinical therapies to treat different symptoms concomitantly may offer the best possible outcomes for the patient. In this review article we describe these aspects.

Canadian Clinical Practice Guidelines for Rosacea

Rosacea is a chronic facial inflammatory dermatosis characterized by background facial erythema and flushing and may be accompanied by inflammatory papules and pustules, cutaneous fibrosis and hyperplasia known as phyma, and ocular involvement. These features can have adverse impact on quality of life, and ocular involvement can lead to visual dysfunction. The past decade has witnessed increased research into pathogenic pathways involved in rosacea and the introduction of novel treatment innovations. The objective of these guidelines is to offer evidence-based recommendations to assist Canadian health care providers in the diagnosis and management of rosacea. These guidelines were developed by an expert panel of Canadian dermatologists taking into consideration the balance of desirable and undesirable outcomes, the quality of supporting evidence, the values and preferences of patients, and the costs of treatment. The 2015 Cochrane review "Interventions in Rosacea" was used as a source of clinical trial evidence on which to base the recommendations.

Guidelines of care for vascular lasers and intense pulse light sources from the European Society for Laser Dermatology

AIM

Lasers and non-coherent intense pulse light sources (IPLS) are based on the principle of selective photothermolysis and can be used for the treatment of many vascular skin lesions. A variety of lasers has been developed for the treatment of congenital and acquired vascular lesions which incorporate these concepts into their design. Although laser and light sources are very popular due to their non-invasive nature, caution should be considered by practitioners and patients to avoid permanent side-effects. The aim of these guidelines is to give evidence-based recommendations for the use of lasers and IPLS in the treatment of vascular lesions.

METHODS

These guidelines were produced by a Consensus Panel made up of experts in the field of vascular laser surgery under the auspices of the European Society of Laser Dermatology. Recommendations on the use of vascular lasers and IPLS were made based on the quality of evidence for efficacy, safety, tolerability, cosmetic outcome, patient satisfaction/preference and, where appropriate, on the experts' opinion. The recommendations of these guidelines are graded according to the American College of Chest Physicians Task Force recommendations on Grading Strength of Recommendations and Quality of Evidence in Clinical Guidelines.

RESULTS

Lasers and IPLS are very useful and sometimes the only available method to treat various vascular lesions. It is of a paramount importance that the type of laser or IPLS and their specific parameters are adapted to the indication but also that the treating physician is familiar with the device to be used. The crucial issue in treating vascular lesions is to recognize the immediate end-point after laser treatment. This is the single most important factor to ensure both the efficacy of the treatment and avoidance of serious side-effects.

Interventions for rosacea

BACKGROUND

Rosacea is a common chronic skin condition affecting the face, characterised by flushing, redness, pimples, pustules and dilated blood vessels. The eyes are often involved and thickening of the skin with enlargement (phymas), especially of the nose, can occur in some people. A range of treatment options are available but it is unclear which are most effective.

OBJECTIVES

To assess the efficacy and safety of treatments for rosacea.

SEARCH METHODS

We updated our searches, to July 2014, of: the Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library (2014, Issue 6), MEDLINE (from 1946), EMBASE (from 1974) and Science Citation Index (from 1988). We searched five trials registers and checked reference lists for further relevant studies.

SELECTION CRITERIA

Randomised controlled trials in people with moderate to severe rosacea.

DATA COLLECTION AND ANALYSIS

Study selection, data extraction, risk of bias assessment and analyses were carried out independently by two authors.

MAIN RESULTS

We included 106 studies, comprising 13,631 participants. Sample sizes of 30-100 and study duration of two to three months were most common. More women than men were included, mean age of 48.6 years, and the majority had papulopustular rosacea, followed by erythematotelangiectatic rosacea.A wide range of comparisons (67) were evaluated. Topical interventions: metronidazole, azelaic acid, ivermectin, brimonidine or other topical treatments. Systemic interventions: oral antibiotics, combinations with topical treatments or other systemic treatments, i.e. isotretinoin. Several studies evaluated laser or light-based treatment.The majority of studies (57/106) were assessed as 'unclear risk of bias', 37 'high risk ' and 12 'low risk'. Twenty-two studies provided no usable or retrievable data i.e. none of our outcomes were addressed, no separate data reported for rosacea or limited data in abstracts.Eleven studies assessed our primary outcome 'change in quality of life', 52 studies participant-assessed changes in rosacea severity and almost all studies addressed adverse events, although often only limited data were provided. In most comparisons there were no statistically significant differences in number of adverse events, most were mild and transient. Physician assessments including investigators' global assessments, lesion counts and erythema were evaluated in three-quarters of the studies, but time needed for improvement and duration of remission were incompletely or not reported.The quality of the body of evidence was rated moderate to high for most outcomes, but for some outcomes low to very low.Data for several outcomes could only be pooled for topical metronidazole and azelaic acid. Both were shown to be more effective than placebo in papulopustular rosacea (moderate quality evidence for metronidazole and high for azelaic acid). Pooled data from physician assessments in three trials demonstrated that metronidazole was more effective compared to placebo (risk ratio (RR) 1.98, 95% confidence interval (CI) 1.29 to 3.02). Four trials provided data on participants' assessments, illustrating that azelaic acid was more effective than placebo (RR 1.46, 95% CI 1.30 to 1.63). The results from three studies were contradictory on which of these two treatments was most effective.Two studies showed a statistically significant and clinically important improvement in favour of topical ivermectin when compared to placebo (high quality evidence). Participants' assessments in these studies showed a RR of 1.78 (95% CI 1.50 to 2.11) and RR of 1.92 (95% CI 1.59 to 2.32),which were supported by physicians' assessments. Topical ivermectin appeared to be slightly more effective than topical metronidazole for papulopustular rosacea, based on one study, for improving quality of life and participant and physician assessed outcomes (high quality evidence for these outcomes).Topical brimonidine in two studies was more effective than vehicle in reducing erythema in rosacea at all time points over 12 hours (high quality evidence). At three hours the participants' assessments had a RR of 2.21 (95% CI 1.52 to 3.22) and RR of 2.00 (95% CI 1.33 to 3.01) in favour of brimonidine. Physicians' assessments confirmed these data. There was no rebound or worsening of erythema after treatment cessation.Topical clindamycin phosphate combined with tretinoin was not considered to be effective compared to placebo (moderate quality evidence).Topical ciclosporin ophthalmic emulsion demonstrated effectiveness and improved quality of life for people with ocular rosacea (low quality evidence).Of the comparisons assessing oral treatments for papulopustular rosacea there was moderate quality evidence that tetracycline was effective but this was based on two old studies of short duration. Physician-based assessments in two trials indicated that doxycycline appeared to be significantly more effective than placebo (RR 1.59, 95% CI 1.02 to 2.47 and RR 2.37, 95% CI 1.12 to 4.99) (high quality evidence). There was no statistically significant difference in effectiveness between 100 mg and 40 mg doxycycline, but there was evidence of fewer adverse effects with the lower dose (RR 0.25, 95% CI 0.11 to 0.54) (low quality evidence). There was very low quality evidence from one study (assessed at high risk of bias) that doxycycline 100 mg was as effective as azithromycin. Low dose minocycline (45 mg) was effective for papulopustular rosacea (low quality evidence).Oral tetracycline was compared with topical metronidazole in four studies and showed no statistically significant difference between the two treatments for any outcome (low to moderate quality evidence).Low dose isotretinoin was considered by both the participants (RR 1.23, 95% CI 1.05 to 1.43) and physicians (RR 1.18, 95% CI 1.03 to 1.36) to be slightly more effective than doxycycline 50-100 mg (high quality evidence).Pulsed dye laser was more effective than yttrium-aluminium-garnet (Nd:YAG) laser based on one study, and it appeared to be as effective as intense pulsed light therapy (both low quality evidence).

AUTHORS' CONCLUSIONS

There was high quality evidence to support the effectiveness of topical azelaic acid, topical ivermectin, brimonidine, doxycycline and isotretinoin for rosacea. Moderate quality evidence was available for topical metronidazole and oral tetracycline. There was low quality evidence for low dose minocycline, laser and intense pulsed light therapy and ciclosporin ophthalmic emulsion for ocular rosacea. Time needed to response and response duration should be addressed more completely, with more rigorous reporting of adverse events. Further studies on treatment of ocular rosacea are warranted.

Clinical efficacy of low-level laser therapy on localized canine atopic dermatitis severity score and localized pruritic visual analog score in pedal pruritus due to canine atopic dermatitis

BACKGROUND

Canine atopic dermatitis is a genetically predisposed inflammatory skin disease often requiring multimodal treatment. There is a need to find further low-risk adjunctive therapies.

HYPOTHESIS/OBJECTIVES

To evaluate the localized effect of low-level laser therapy (LLLT) on the paws of dogs with atopic dermatitis using a localized canine atopic dermatitis severity score (LCADSS) and owner localized pruritic visual analog score (LPVAS) in comparison to treatment with a placebo.

ANIMALS

Thirty client-owned dogs with symmetrical pedal pruritus due to canine atopic dermatitis.

METHODS

Dogs were randomly assigned into two groups. In each group, one paw was treated with LLLT and one paw treated with a placebo laser (comparing either both fore- or hindpaws). Treatments were administered at 4 J/cm(2) (area from carpus/tarsus to distal aspect of digit 3) three times per week for the first 2 weeks and two times per week for the second 2 weeks. Scores were assessed for each paw at weeks 0, 2, 4 and 5.

RESULTS

There were no significant differences in LCADSS or LPVAS between LLLT and placebo treatments between weeks 0 and 5 (P = 0.0856 and 0.5017, respectively). However, LCADSS and LPVAS significantly decreased from week 0 at weeks 2, 4 and 5 in both LLLT and placebo groups (P < 0.0001 for all).

CONCLUSIONS AND CLINICAL IMPORTANCE

Low-level laser therapy is not an effective localized treatment for pedal pruritus in canine atopic dermatitis.

Refinements in brow reconstruction: synergy between plastic surgery and aesthetic medicine

OBJECTIVE

The purpose of this study was the introduction in clinical practice of the combined application of traditional reconstructive surgery and intense pulsed light (IPL) for the restoration of a post-traumatic eyebrow defect.

CASE

The authors present a case of surgical eyebrow reconstruction with an axial temporal hair-bearing scalp island flap. A persistent localized erythema and a marked difference in hair density in comparison with the contralateral one harmed the eventual surgical outcome.

RESULTS

A combined sequential treatment with IPL achieved both hair density and skin erythema reduction, and eventually allowed for a very satisfactory result.

CONCLUSIONS

Our experience demonstrated the efficacy of the integrated multidisciplinary approach involving traditional plastic reconstructive surgery and the innovative new technologies in aiming for perfection.

Comparative effectiveness of nonpurpuragenic 595-nm pulsed dye laser and microsecond 1064-nm neodymium:yttrium-aluminum-garnet laser for treatment of diffuse facial erythema: A double-blind randomized controlled trial

BACKGROUND

Facial erythema is a common symptom that responds to vascular laser treatment, but there are few comparative studies.

OBJECTIVE

We sought to compare the effectiveness of microsecond 1064-nm neodymium:yttrium-aluminum-garnet (Nd:YAG) laser with nonpurpuragenic 595-nm pulsed dye laser (PDL) for diffuse facial erythema.

METHODS

This was a split-face, double-blind randomized controlled trial. Bilateral cheeks received 4 treatments each at one month intervals with PDL or Nd:YAG. Spectrophotometer measurements, digital photographs, pain scores, and patient preferences were recorded.

RESULTS

Sixteen patients enrolled and 2 dropped out. Fourteen patients, all skin types I to III, 57% women, mean age 42 years, completed the study and were analyzed. Spectrophotometer readings changed after both PDL (8.9%) and Nd:YAG (2.5%), but varied by treatment type, with PDL reducing facial redness 6.4% more from baseline than Nd:YAG (P = .0199; 95% confidence interval -11.6 to -1.2). Pain varied (P = .0028), with Nd:YAG associated with less pain, at 3.07, than PDL at 3.87. Subjects rated redness as improved by 52% as a result of PDL, and 34% as a result of Nd:YAG (P = .031; 95% confidence interval -34.6 to -1.94). No serious adverse events were observed.

LIMITATIONS

Lasers settings are not standardized across devices.

CONCLUSION

Facial erythema is safely and effectively treated with PDL and Nd:YAG. Nonpupuragenic PDL may be more effective for lighter-skinned patients, but microsecond Nd:YAG may be less painful.

Dermatofibromas treated with pulsed dye laser: Clinical and dermoscopic outcomes

Dermatofibroma (DF), a common benign skin tumour, sometimes requires treatment either because of cosmetic concern or for associated symptoms. However, no effective treatment with optimal cosmetic outcomes has been reported. An effective and safe therapeutic option could be treatment with pulsed dye laser (PDL). Twenty-two DFs in 15 patients were treated with PDL at 595-nm wavelength, using a spot size of 7 mm, a pulse duration of 2 ms and a fluence of 11 J/cm(2) with 2 or 3 stacked pulses. Clinical and dermoscopic photographs were taken before and after therapy. Global clinical improvement was higher than 50% in 12 lesions. Patient satisfaction assessment showed 73% of patients as satisfied or very satisfied. All lesions showed changes from the previous dermoscopic pattern. We consider that PDL could be a safe, palliative treatment as it is well accepted by patients and has a better cosmetic outcome than surgical excision.

Interventions for rosacea

BACKGROUND

Rosacea is a common chronic skin condition affecting the face, characterised by flushing, redness, pimples, pustules, and dilated blood vessels. The eyes are often involved and thickening of the skin with enlargement (phymas), especially of the nose, can occur in some patients. A range of treatment options are available but it is unclear which are the most effective.

OBJECTIVES

To assess the evidence for the efficacy and safety of treatments for rosacea.

SEARCH STRATEGY

In February 2011 we updated our searches of the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (Clinical Trials) in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index, and Ongoing Trials Registers.

SELECTION CRITERIA

Randomised controlled trials in people with moderate to severe rosacea.

DATA COLLECTION AND ANALYSIS

Study selection, data extraction, assessment of risk of bias, and analyses were carried out by two independent review authors.

MAIN RESULTS

Fifty-eight trials, including 27 from the original review, comprising 6633 participants were included in this updated review. Interventions included topical metronidazole, oral antibiotics, topical azelaic cream or gel, topical benzoyl peroxide and/or combined with topical antibiotics, sulphacetamide/sulphur, and others. Only two studies assessed our primary outcome 'quality of life'.Pooled data from physician assessments in three trials provided some evidence that metronidazole was more effective compared to placebo (RR 1.95, 95% CI 1.48 to 2.56). Three trials provided data, based on participants' assessments, illustrating azelaic acid was more effective than placebo (RR 1.52, 95% CI 1.32 to 1.76).Physician-based assessments in two trials indicated that doxycycline appeared to be significantly more effective than placebo (RR 1.59, 95% CI 1.02 to 2.47 and RR 2.37, 95% CI 1.12 to 4.99). There was no statistically significant difference in effectiveness between 100 mg and 40 mg doses of doxycycline, but there was evidence of less adverse effects with the lower dose (RR 0.25, 95% CI 0.11 to 0.54).One study reported that cyclosporine ophthalmic emulsion was significantly more effective than artificial tears for treating ocular rosacea (for all outcomes).

AUTHORS' CONCLUSIONS

Although the majority of included studies were assessed as being at high or unclear risk of bias there was some evidence to support the effectiveness of topical metronidazole, azelaic acid, and doxycycline (40 mg) in the treatment of moderate to severe rosacea, and cyclosporine 0.5% ophthalmic emulsion for ocular rosacea. Further well-designed, adequately-powered randomised controlled trials are required.