Rosacea is a long-standing, common inflammatory skin disease of unknown origin [1]. Erythematotelangiectatic rosacea is one of the four subtypes of rosacea [2], its main feature is central facial erythema (forehead region, nasal area, chin, and malar area), with manifestations ranging from sebaceous gland hyperplasia to blood vessels hyperactivity [3]. The sensation of ocular stinging is present in some cases [4,5]. In severe cases, rhinophyma can occur with an increase in the thickness of the affected skin [6].

It has been estimated that rosacea affects approximately 1% to 22% of the general population in different localities [7]. It also affects pigmented skinned people, Asians, and Caucasians. It has been stated to affect 2% to 3% of Asians according to a large-scale study [8]. Disease onset is usually during the childhood and teenage stages, and exacerbation is usually seen in early adulthood due to psychosocial, lifestyle, and dietary factors.

Female patient, a 29 year-old secondary school teacher, presented at our clinic complaining of a 5-year history of intermittent facial flushing associated with facial rashes. During this period, the condition was severe, and she had the sensation that her face became swollen and tight whenever she experienced the facial flushing. Whenever she drank alcohol, ate spicy food, or practiced hot yoga, her condition worsened. She was a nonsmoker and had an unremarkable medical history. She withdrew from outdoor activities, such as hiking, as her facial flushing worsened. She felt worried and embarrassed whenever the facial flushing occurred, as people around always asked her what had happened. She also withdrew from social gatherings as the facial flushing always occurred whenever she felt nervous.

Patient believed it was a kind of skin allergy, and this on and off phenomenon triggered her to do ‘doctor shopping’. She believed that her immune system was ‘weak’ and required herbal tea to ‘drain the dampness’ from her body. She tried different types of herbal medicines, but stopped taking them after finding that they were not effective. She then changed her focus to skin products and tried several different products to treat the facial flushing. Once again, she felt disappointed, as they seemed to cause irritation and rather exacerbate the symptoms.

Patient finally remembered that Western medicine might have a chance to help her condition. She sought help from two family physicians. The first family physician diagnosed her condition as allergic contact dermatitis, and the culprit was the topical skin product she used daily. She was prescribed a topical steroid and asked to apply it twice daily. Her condition improved, and she continued this practice for 7 months. One day, she consulted another family physician because the condition had worsened, and her face turned purple even with the application of the topical steroid. The second family physician diagnosed her condition as rosacea and prescribed oral tetracycline and topical metronidazole cream. Her facial flushing improved slightly, but was still on and off, thus affecting patient. Nevertheless, her husband wanted her to withhold all oral medications because of their pregnancy plan.

Patient facial flushing continued to worsen during the last six months before her visit to our clinic. On the consultation day, she felt worried and cried; she said she wanted to quit her teacher job because her colleagues and students often stared at her face. She did not experience any suicidal ideation. No other systemic symptoms, such as dysphagia or muscle weakness, were noticed, apart from her facial skin problem.

On physical examination, a poorly defined diffuse erythema was observed her face (Fig. 1). The erythema was located all over her chin, cheek, perioral, nasal, and frontal. Other body parts such as the chest, neck, and palms were not affected. The affected areas had a rough texture. Multiple papules and telangiectasia were also observed. Patient’s skin was Fitzpatrick type IV (dark hair and light Mediterranean olive-looking skin; beige with a light brown tint. They typically tan with ease and seldom get burned). No other signs were observed during the systemic examination. Her mental status was stable. We received the patient’s consent form about publishing all photographic materials.

Figure 1. Patient’s frontal area before undergoing the first intense pulsed light treatment.

Management

Erythematotelangiectatic rosacea was clinically diagnosed and no further investigations were performed. No skin biopsies were performed. Patient was taught that it was a disease that could only be controlled but not completely cured. She needed to be patient and comply with the treatment we provided to her to control the exacerbations. Triggering factors such as hot environments (hot yoga), stress, spicy food, and alcohol consumption were prohibited. She was instructed to carefully choose her skincare products. She was also instructed to avoid alcohol-containing cosmeceuticals, and to use preservative and fragrance-free products to reduce the number of exacerbations.

Owing to her pregnancy plan, isotretinoin (pregnancy category X) [9] and tetracycline (pregnancy category D) [9] were not applicable. Topical metronidazole (pregnancy category B) [9] was not a bad treatment choice for her, but she tried it before without success and therefore thought it could not help her situation.

We treated her with intense pulsed light. A urine pregnancy test was performed prior to every intense pulsed light treatment session. She received eight sessions, once every 4 weeks. The parameters of the laser settings are shown in Fig. 2.

Figure 2. Intense pulsed light treatment parameters for erythematotelangiectatic rosacea patients.

Her facial erythema improved as the number of telangiectasia decreased. No purpura was seen (Fig. 3). During each visit, we were particularly concerned about her psychological well-being. She appeared happier once her skin condition began to improve. We encouraged her to seek more family support, and her husband emphasized that he would take good care of her.

Figure 3. Female patient face 2 weeks after the 8th session of intense pulsed light treatment.

After the 8th treatment session, patient became pregnant and the intense pulsed light treatment was discontinued. Although the erythema persisted, patient was already very happy with the clinical results.

Rosacea is a chronic incurable condition. It usually recurs once patients come in contact with the triggering factors. Thus, it is important to teach patients how to avoid precipitants (stress, extreme temperatures, alcohol consumption, spicy food consumption, and exposure to sunlight). Both patients and doctors play important roles in the management of this condition. The use of cosmetics and skincare products is of utmost importance.

Treatment modalities for erythematotelangiectatic rosacea includes topical metronidazole [10], azelaic acid, pimecrolimus, tacrolimus, clindamycin, and sodium sulfacetamide [11]; oral medications such as tetracycline [12], metronidazole [11], clarithromycin [11], and isotretinoin [12]; and light therapy such as 535 nm potassium titanyl phosphate laser, 575 nm pulsed dye laser, 810 nm diode laser, and 1,064 nm Nd:YAG laser [13], or intense pulsed light [14].

A study was conducted on 50 erythematotelangiectatic rosacea patients and it was found that intense pulsed light may be more effective in younger patients and in those with more severe erythema [15].

In another study, a split-face randomized controlled trial was performed on 29 patients with erythematotelangiectatic rosacea [16]. One side of the face was treated with intense pulsed light and the other side was treated with a pulsed dye laser. All patients received three sessions of treatment, one month apart. A blinded observer’s reports and patients’ self-responses were recoded. No significant differences in the final outcome were noted between the two sides, although improvements were reported on both sides.

In another split-face randomized controlled trial involving nine patients with rosacea [17], every patient underwent a pulsed dye laser therapy on one side of the face and a short pulsed intense pulsed light therapy on the other side. They all underwent four treatments sessions with the same fluence and pulse duration. It was found that there was no significant difference between intense pulsed light and pulsed dye laser in terms of decreasing erythema.

Finally, in a systematic review and meta-analysis on the use of intense pulsed light versus pulsed dye laser for treating facial erythema in rosacea, it was found that there were no significant differences between the two techniques regarding their effects in decreasing erythema [18].

We believe intense pulsed light treatment is very effective in decreasing erythema; its efficacy is comparable to that of pulsed dyed laser, which is the first-line treatment for telangiectasia in erythematotelangiectatic rosacea.

From this case report, we found that intense pulsed light can help decrease erythema in patients with severe erythematotelangiectatic rosacea. More research is needed to evaluate post-intense pulsed light therapy tissue histological changes, long-term sustainable results, and optimal treatment parameters. Furthermore, patient selection is important. Potential complications with intense pulsed light include post-inflammatory hyperpigmentation, burns, and pain [14].

The authors have nothing to disclose.