Narrow-Band Intense Pulsed Light as Treatment for Erythematotelangiectatic Rosacea: A Retrospective Study.

BACKGROUND: Erythematotelangiectatic rosacea can be successfully treated using various laser and light-based devices. However, the use of narrow-band intense pulsed light for the treatment of erythematotelangiectatic rosacea has not been investigated in detail. This retrospective study aimed to analyze the clinical efficacy of narrow-band intense pulsed light (500-600 nm) for the treatment of erythematotelangiectatic rosacea among Chinese individuals.  Methods: Patients with erythematotelangiectatic rosacea who had completed 3 sessions of treatment with narrow-band intense pulsed light and follow-up from July 2016 to December 2018 were retrospectively evaluated. Clinical improvement was assessed by 2 blinded dermatologists based on photographs obtained at each follow-up visit using the clinician erythema assessment scale and 5-grade scale. RESULTS: Forty-five patients with erythematotelangiectatic rosacea treated with narrow-band intense pulsed light were included in this study. The effectiveness and excellent rates after 3 treatment sessions were 68.9% and 35.6%, respectively. An average of 2 treatment sessions was required among patients who achieved good or excellent clearance of erythema and telangiectasia. Except for transient erythema and edema, no severe adverse effects were observed. CONCLUSIONS: Narrow-band intense pulsed light is a safe and effective treatment for erythematotelangiectatic rosacea. Even with a small number of treatment sessions, narrow-band intense pulsed light can deliver a significant therapeutic effect, which may be applicable in clinical practice. J Drugs Dermatol. 2023;22(11):1095-1098     doi:10.36849/JDD.4920.

Clinical and histological features and treatment outcomes of patients with Morbihan disease: a systematic review.

Morbihan disease (MD) is considered a rare complication of rosacea, which is difficult to diagnose and challenging to treat. Here, we performed a systematic review of available case reports and case series to summarize key clinical and pathologic features of and successful treatment regimens for MD. We conducted a search of the PubMed/MEDLINE, EMBASE, and Cochrane electronic databases from their inception to the date of search on March 6, 2023. We found that MD affects patients in the fifth decade of life on average, more commonly reported in male than female (69% vs 31%). Clinically, MD affects the eyelids, cheeks, and forehead most commonly, presenting as non-pitting, erythematous edema or an edematous plaque. On biopsy, the pathologic features, such as dermal edema, sebaceous hyperplasia, perivascular and periadnexal inflammatory infiltrate, and granulomatous reaction, are frequently reported. Out of 55 patients who were able to achieve complete response without recurrence, 35% of patients were treated with isotretinoin and 22% were treated with tetracycline antibiotics with a daily dosage range of 20-80 mg and 40-200 mg, respectively. Out of those 55 patients, 22% and 7% were treated successfully with surgical intervention and intralesional injection of steroids, respectively. Additionally, lymphatic drainage has been shown to be an effective adjunctive therapeutic tool. More studies are necessary to understand the disease mechanism to improve the diagnosis of and develop evidence-based therapies for MD.

Paediatric ocular rosacea: diagnosis and management with an eyelid-warming device and topical azithromycin 1.5.

BACKGROUND: Ocular rosacea is a chronic inflammatory disorder with periods of exacerbation and remission, often underdiagnosed in children. When diagnosed, its management is challenging because of a lack of effective long-term treatment options. OBJECTIVE: To report our experience in cases of pediatric ocular rosacea treated with moist heat therapy and topical azithromycin 1.5%. METHODS: The medical records of six children diagnosed with ocular rosacea based on a careful medical history and slit-lamp examination of the eyelids and ocular surface were reviewed. Previous treatments were discontinued, and children/parents were instructed to use the eyelid-warming device for 1 or 2 sessions of 10minutes each day, followed by eyelid massage and cleansing, in combination with azithromycin 1.5% eye drops. RESULTS: The diagnosis of ocular rosacea in these children was delayed for several months or years from the first identifiable clinical sign or symptom. All the children presented with corneal sequelae and decreased vision. Ocular manifestations included meibomian gland disease, recurrent chalazia, and phlyctenular keratoconjunctivitis. Cutaneous signs were not always associated with the condition. Ocular rosacea was usually resistant to initial treatments with antibiotics and topical corticosteroids. Treatment with the eyelid-warming device in combination with azithromycin 1.5% led to a rapid improvement in the clinical signs and was well tolerated by all patients. CONCLUSIONS: Childhood ocular rosacea is potentially sight threatening. Practitioners should consider this condition in order to minimise diagnostic delay and subsequent complications. Combined therapy of eyelid hygiene (including an eyelid warming device) and azithromycin 1.5% eye drops was effective in treating ocular rosacea in children.

The impact of clinical nutrition on inflammatory skin diseases.

The influence of nutrition on the pathophysiology and clinical severity of inflammatory facial dermatoses such as acne, rosacea, seborrheic dermatitis, and perioral dermatitis has been controversially discussed for years. As part of a modern treatment approach, clinicians should provide patients with information on how their choice of diet might impact their dermatologic diagnosis and could potentially enhance therapeutic outcome. Recently, the concept of a gut-skin axis has gained momentum in the understanding of inflammatory dermatoses, with nutrition considered a contributing factor in this context. For example, gastrointestinal symptoms in rosacea patients may indicate a dysbiosis of the gut microbiome, treatment of which may also improve severity of the skin disease. New research efforts were recently made for acne patients addressing the clinical effects of omega-3 fatty acids and probiotics. In contrast, due to the limited data available, no comparable specific dietary recommendations can yet be made for seborrheic or perioral dermatitis. However, there are promising signs that clinical nutrition and dermatology will be more extensively interlinked in the future, both clinically and scientifically.

Rosacea: An Update in Diagnosis, Classification and Management.

The diagnosis and classification of rosacea has been modified to reflect presenting features. On exclusion of differentials, the diagnosis of rosacea is based on the presence of either (1) phymatous changes, or (2) centrofacial persistent erythema. In their absence, diagnosis can be established by presence of any two of: flushing/transient erythema, papules and pustules, telangiectases, or ocular manifestations. Management of rosacea depends on presenting feature(s), their severity, and impact. General management includes gentle skin care, sun protection, and trigger avoidance. Evidence-based treatment recommendations include topical brimonidine and oxymetazoline for persistent erythema; topical azelaic acid, ivermectin, metronidazole, minocycline and oral doxycycline, tetracycline and isotretinoin for papules and pustules; vascular lasers and light devices for telangiectases; and omega-3 fatty acids and cyclosporine ophthalmic emulsion for ocular rosacea. While surgical or laser therapy can be considered for clinically noninflamed phyma, there are no trials on their utility. Combination therapies include topical brimonidine with topical ivermectin, or topical metronidazole with oral doxycycline. Topical metronidazole, topical ivermectin, and topical azelaic acid are appropriate for maintenance therapy. In conclusion, the updated phenotype approach, based on presenting clinical features, is the foundation for current diagnosis, classification, and treatment of rosacea.

Relationship Between Tea Drinking Behaviour and Rosacea: A Clinical Case-control Study.

The exact mechanisms of rosacea development are unknown, but it has been suggested that tea consumption may be associated with its development. To determine the relationship between tea drinking behaviour and rosacea, this clinical case-control study recruited 2,063 participants, who completed a questionnaire about tea drinking behaviour. A 1:1 ratio propensity score matching method was used to generate 619 cases and 619 controls. High-frequency tea drinking (3 times/day: adjusted odds ratio (aOR) 2.592; 95% confidence interval (95% CI) 1.225-5.485; ≥ 4 times/day; aOR 8.86; 95% CI 3.43-22.887), non-fermented tea (aOR 2.172; 95% CI 1.562-3.022), and hot tea (aOR 2.793; 95% CI 1.796-1.344) were associated with an increased risk of rosacea. Further results showed that these tea drinking behaviours were significantly associated with an increased risk of flushing (aOR 1.41; 95% CI 1.07-1.87) and erythema (aOR 1.48; 95% CI 1.10-2.00). Tea drinking behaviour is closely related to rosacea and.

Rosacea.

Rosacea is a common cutaneous condition affecting predominantly the face. It is historically characterised into four subtypes: erythematotelangiectatic, papulopustular, phymatous and ocular rosacea. This article describes the pathophysiology, clinical features and current treatment options for rosacea, and discusses updated diagnostic criteria. General guidance is required on the need to avoid possible triggers including dietary and environmental triggers. The strongest evidence supports the use of 0.75% metronidazole, topical azelaic acid or topical ivermectin for inflammatory rosacea. Erythema should be treated with brimonidine tartrate gel, oral medication such as beta blockers or vascular laser and light-based therapy. Oral doxycycline 40 mg modified release can be used as monotherapy or in combination with other treatments for recalcitrant disease. Further understanding of the pathogenesis of rosacea could allow identification and targeted avoidance of triggers and the development of new treatment modalities.

Efficacy of Topical Ivermectin for the Treatment of Cutaneous and Ocular Rosacea.

Purpose: To investigate the efficacy of once-daily topical treatment of ocular and cutaneous rosacea with ivermectin 1% cream (Soolantra®, Galderma).Methods: Ten patients with rosacea were evaluated in a retrospective monocentric pilot study. Subjective symptoms (measured with the Ocular Surface Disease Index), skin findings, and ocular changes (blepharitis with telangiectasia and meibomian gland dysfunction, conjunctival redness, tear breakup time (TBUT), and fluorescein staining of the cornea) were evaluated. The follow-up was 8 months (range: 5-12 months).Results: The OSDI score decreased in the 8th week of treatment (38.5 ± 21.7, P = .004). After 16 weeks, blepharitis (P = .004), and conjunctival redness (P = .008) had strongly improved, and grade 1 was seen in all patients until the end of follow-up. Fluorescein staining of the cornea (P = .001) and TBUT (P = .016) showed significant improvement until the last follow-up visit. No side effects were observed. Conclusion: Topical ivermectin cream 1% given daily is an effective and safe therapy against rosacea.

Combined treatment of recalcitrant papulopustular rosacea involving pulsed dye laser and fractional microneedling radiofrequency with low-dose isotretinoin.

BACKGROUND: While a considerable number of cases with papulopustular rosacea (PPR) are resistant to conventional medications, therapeutic regimens are not currently established. Pulsed dye laser (PDL) and fractional microneedling radiofrequency (FMR) have previously demonstrated satisfactory results for anti-angiogenesis, anti-inflammation, and dermal remodeling. AIMS: To evaluate the efficacy and safety of novel combination regimen with low-dose oral isotretinoin, PDL, and FMR in the treatment of recalcitrant PPR. PATIENTS AND METHODS: A retrospective study was undertaken for recalcitrant PPR patients to evaluate the clinical course of novel combination regimen. Twenty-five PPR patients who had failed in previous first-line therapies were enrolled. They were treated with three sessions of PDL and FMR consecutively at 4-week intervals, maintaining daily oral administration of 10 mg isotretinoin for 8 weeks. Objective assessments, erythema index measurement, and patients' subjective satisfaction were evaluated at each visit and 16 weeks after the final treatment. RESULTS: At the final follow-up visit, the number of papules and pustules decreased by 71%, and erythema index by 54% compared with baseline (P < 0.05 for both). Physician's global assessment based on rosacea severity score and patients' subjective assessments paralleled with these results. No serious side effect was observed during whole study periods. CONCLUSION: This novel combination regimen demonstrated satisfactory efficacy with reasonable safety profiles for the treatment of recalcitrant PPR.

Rosacea: a wholistic review and update from pathogenesis to diagnosis and therapy.

Rosacea is a chronic inflammatory disorder of the central face with multiple overlapping presentations. Recent advancements are reshaping our understanding of rosacea from both a pathophysiologic perspective and clinical approach to therapy, introducing novel agents that have improved patient outcomes and reduced morbidity. In this article, we aim to outline the advancements in understanding, diagnosing, and managing rosacea and to familiarize physicians with the literature, thereby allowing us to better practice safe and effective medicine.

The efficacy and safety of permethrin 2.5% with tea tree oil gel on rosacea treatment: A double-blind, controlled clinical trial.

BACKGROUND: Rosacea is a chronic skin condition that typically affects the face and it results in redness and inflammation. The main risk factors of this disease are Demodex folliculorum, living in the pilosebaceous units. AIMS: To evaluate the efficacy and safty of permethrin 2.5% in combination with tea tree oil (TTO) topical gel versus placebo on Demodex density (Dd) and clinical manifestation using standard skin surface biopsy (SSSB) in rosacea patients. PATIENT/METHODS: In this double-blind, randomized clinical trial, 47 papulopustular rosacea patients were enrolled, with 35 patients finishing the 12 weeks of treatment. Each patient used permethrin 2.5% with TTO on one side of the face and a placebo on the other, twice daily for 12 weeks. SSSB, photography and clinical rosacea scores according to National Rosacea Society, as well as adverse drug reaction (ADRs) were reported at the baseline, 2nd, 5th, 8th, and 12th weeks. RESULTS: A total of 47 patients were enrolled with papulopustular rosacea, and 35 patients finished the study. The effects of permethrin 2.5% with TTO gel on mite density were significant at week 5, 8, 12 (P value = .001). Clinical features and global assessments showed papules, pustules and nontransient erythema had improvement in drug group after 12 weeks (P values <.05). The improvement of burning and stinging and dry appearance was greater than the placebo gel (P value <.05). Itching in placebo group was significantly more than other group (P value = .002). CONCLUSION: Administration of permethrin 2.5% with TTO gel demonstrated good efficacy and safety in rosacea. This topical gel inhibited the inflammatory effects of rosacea and reduced Demodex mite.

Open-label study assessing the efficacy and tolerability of topical skin care and sun protection alone and in combination with intense pulsed light therapy.

BACKGROUND: Intense pulsed light therapy (IPL) decreases facial erythema and telangiectasias associated with rosacea. Topical skin care products decrease facial erythema by the action of active ingredients and masking effects. OBJECTIVES: To assess the efficacy and tolerability of combining a topical skin care regimen (TSCR) comprised of a multifunctional three-in-one facial cream and a mineral-based brush-on SPF50 powder sunscreen with a single IPL treatment for treating mild-to-severe facial redness associated with rosacea. METHODS: Twenty female subjects with Fitzpatrick skin types I-III received TSCR monotherapy for 12 weeks. At that time, subjects received a single IPL treatment and continued TSCR for 6 additional weeks. Subjects were evaluated at Baseline and at Weeks 4, 8, 12, and 18. RESULTS: Using a 7-point redness scale, the overall mean (SD) redness score significantly improved from 3.05 (0.97) at baseline to 2.05 (0.76) at Week 18 (P < 0.01). There was a decrease in investigator-rated erythema from baseline (bare skin) to Week 12 (bare skin, before IPL) when TSCR was used as monotherapy which did not achieve significance (P = 0.12). Most subjects (80%) were satisfied or Very satisfied with the TSCR at Week 18. All subjects (100%) agreed that it improved their baseline skin redness and most (85%) would recommend TSCR to others. TSCR was well-tolerated with no significant changes in skin dryness, scaling, or itching. Mild burning occurred immediately following the IPL treatment at Week 12. CONCLUSION: TSCR in combination with a single IPL treatment produced a significant improvement in overall facial redness in patients with rosacea. Longer-term treatment with TSCR may produce continued improvement.

Natural Skin Care Products as Adjunctive to Prescription Therapy in Moderate to Severe Rosacea

Background: Rosacea is characterized by irritation associated with erythema, telangiectasias and papules/pustules. Whole formula nature-based sensitive skin products are formulated to maintain skin barrier and appropriate hydration that can lead to soothing benefits. Objective: To evaluate the efficacy and tolerability of a regimen consisting of a cleanser containing natural oils, beeswax, and witch hazel and day and night creams containing natural oils, glycerin, and botanical anti-inflammatories (NR); and a synthetic dermatologist-recommended regimen of cetyl alcohol, sodium lauryl sulphate-containing cleanser, and glycerin, polyisobutene-containing lotion (CR) in subjects with rosacea. Methods: 80 female subjects with rosacea who received 6 weeks of 0.75% metronidazole gel, were randomized to receive NR or CR, twice daily, for 4 weeks in conjunction with the gel. Blinded investigator global assessment of rosacea, investigator-rated, and subject-rated overall skin appearance was assessed using a 5-point scale (0=none, 4=severe) at baseline, 2 weeks, and 4 weeks. Noninvasive skin assessments for skin hydration and skin barrier function were made by corneometry and TEWL, respectively. Results: NR resulted in improvement in investigator global assessment of rosacea measures at 4 weeks from baseline (erythema, 28%; telangiectasia, 26%; papules/pustules, 34%: P<0.001) and CR resulted in a 8 to 12% improvement. Differences between treatments were statistically significant. Overall skin appearance measured by the investigator was clinically and statistically improved from baseline by 32% and 12% with NR and CR, respectively. Overall skin appearance measured by subjects was improved by both NR and CR from baseline with no differences between treatments. Both regimens improved barrier function from baseline to week 4 (13%, NR; 14%, CR). NR decreased hydration by 21% from baseline at week 4 while CR increased hydration by 14% (P<0.001 from NR). No clinically significant tolerability issues were reported in either regimen at week 4. Conclusion: NR was effective, well tolerated, and superior to CR in the management of rosacea, concomitantly treated with metronidazole. National Clinical Trial Identifier: NCT03392558 J Drugs Dermatol. 2019;18(2):141-146.

Relationship between rosacea and dietary factors: A multicenter retrospective case-control survey.

Although patients with rosacea often consult dermatologists for dietary factors that might be related to their skin disorders, few studies have been conducted to research the relationship between rosacea and dietary factors. The purpose of this study was to evaluate the potential relationship between rosacea and diet among the large Chinese population with rosacea, which would provide dietary guidelines for patients with rosacea. A multicenter case-control study was conducted. The feeding frequency 2 years before the occurrence of rosacea was collected by standardized questionnaires. Multiple logistic regression analysis was used to calculate risks related to the diet. One thousand three hundred and forty-seven patients with rosacea and 1290 controls were enrolled in our study. We found that high-frequency intake of fatty food and tea presented a positive correlation with rosacea, while high-frequency dairy product intake showed significant negative correlation with rosacea. Sweet food, coffee and spicy food appeared to be independent of any subset of rosacea in our study. However, high-frequency dairy product intake showed a borderline beneficial effect on rosacea severity. We further analyzed the correlation between diet and the subtype of rosacea. We found that high-frequency fatty intake was associated with erythematotelangiectatic rosacea (ETR) and phymatous rosacea, while high-frequency tea intake was only associated with ETR. In addition, high-frequency dairy product intake showed negative correlations with ETR and papulopustular rosacea. Rosacea is associated with some dietary factors, and our study is valuable in establishing dietary guidelines to prevent and improve rosacea.

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.

Long-term effects of intense pulsed light treatment on the ocular surface in patients with rosacea-associated meibomian gland dysfunction.

PURPOSE: We aimed to determine the long-term effects of intense pulsed light (IPL) treatment in rosacea-associated meibomian gland dysfunction (MGD). METHODS: We enrolled 17 rosacea subjects with moderate and severe MGD who underwent four IPL sessions at 3-week intervals and were followed up for 12 months. The subjects underwent clinical examinations at baseline (first IPL) and at 3 (second), 6 (third), 9 (fourth), and 12 weeks, as well as 6 and 12 months, after baseline. Ocular surface parameters, including the Ocular Surface Disease Index (OSDI), tear break-up time (TBUT), staining score, and noninvasive Keratograph tear break-up time (NIKBUT), as well as meibomian gland parameters, including the lid margin vascularity and meibum expressibility and quality, were evaluated. RESULTS: All ocular surface and meibomian gland parameters for all subjects exhibited significant changes from baseline to the final examination (Friedman, P < 0.050 for all). In particular, improvements in the lower lid margin vascularity, meibum expressibility and quality, and ocular symptoms persisted up to the final examination (Wilcoxon, P < 0.050 for all). However, the improvements of TBUT, staining score, and NIKBUT after IPL were not maintained at 6 and 12 months after baseline. CONCLUSIONS: In rosacea-associated MGD, four IPL treatments at 3-week intervals can improve long-term lid parameters and ocular symptoms without adverse effects.

A Biologically Based Approach to Acne and Rosacea.

Complementary and alternative medicine (CAM) therapies are increasing in popularity in the field of dermatology. Natural products and holistic approaches are in high demand among patients and research has begun to support their roles in acne and rosacea pathophysiology. In this article, commonly utilized biologically based complementary and alternative therapies for acne and rosacea are reviewed from an evidence-based perspective. Therapies discussed include vitamin C, nicotinamide, zinc, tea tree oil, green tea, resveratrol, curcumin, feverfew, licorice, chamomile, polypodium leucotomos, and nutrition-based approaches. J Drugs Dermatol. 2018;17(6):611-617.

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.

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.