Rosacea and Lasers with Dr. James Wang

[Intro] Hey, everyone. Welcome back to Facially Conscious with myself, Trina Renea, esthetician, Dr. Vicki Rapaport, dermatologist, Rebecca Gadberry, the cosmetic ingredient guru, and our fabulous, overly-educated consumer, Julie Falls. We are gathered here together with you to talk about this crazy world of esthetics. It's confusing out there in this big wide world. 

That's why we are here to help explain it to you all, subject by subject. We will be your go-to girls, and from our perspective without giving medical advice, we will keep things facially conscious.

Let's get started. 

00:59 Julie Falls: Welcome to Facially Conscious. I'm Julie Falls. I am the educated consumer, and I am here with my co-host, Trina, our esthetician extraordinaire, Rebecca, our cosmetic chemistry professor…

01:18 Trina Renea: Scientist.

01:19 Julie Falls: Scientist. 

01:20 Rebecca Gadberry: Scientist, yeah. 

01:21 Julie Falls: Rock star. As I've learned lately all kinds of incredible things that you are developing. 

01:25 Rebecca Gadberry: Rocking on. 

01:28 Julie Falls: And of course, Dr. Vicki Rapaport, our resident fantastic dermatologist, Beverly Hills dermatologist. 

01:38 Trina Renea: To the stars.

01:38 Julie Falls: To the stars. Everyone here is to the stars.

This is our final episode in our series on rosacea, as it's still rosacea month. So who else would we want to join us to talk about rosacea other than our other resident dermatologist, Dr. James Wang. This is his third, fourth visit with us?

02:04 Trina Renea: I think fourth, maybe, episode. 

02:04 Julie Falls: Fourth, okay. And just very quickly…

02:07 Trina Renea: Our laser specialist. 

02:08 Julie Falls: Our laser specialist. Very quickly, he is a Harvard and UCLA-trained, double board-certified dermatologist and a dermatopathologist. He specializes in diagnosing and treating skin cancer, psoriasis, eczema, and acne, including the safe use of Accutane. 

He's also an expert in anti-aging skincare, injectables, as well as, talk about to the stars, laser treatments for scars, sunspots and broken blood vessels. He has been named each year as super doctor, top doctor, and top dermatologist in various publications in Los Angeles area. Welcome, Dr. Wang.

02:47 Dr. James Wang: Thank you for the generous introduction. It's always great to be back to talk about all things skin. It's always my favorite topic, as is yours as well. 

02:58 Julie Falls: Yes, we can't get enough of that. We can't get enough of you. 

So because it is rosacea month, what is your favorite laser for rosacea?

03:11 Dr. James Wang: I've used a lot of lasers in the past. I think really in the last 12 to 24 months, there has been some significant developments in technology that have really pushed the field forward. There hasn't really been anything truly revolutionary probably in the last 10 years or so, since the initial improvements on the old PDL and Vbeam lasers have been doing, which do a very nice job in most particular cases, but there are some issues that they can't address really well. 

The most recent one that has come out is called DermaV, which is a different type of laser, but we are seeing really phenomenal results in very few sessions in most of our patients. 

03:55 Trina Renea: Okay. So DermaV targets red in the skin, or specifically rosacea or all kinds of veins and things?

04:07 Dr. James Wang: It's very versatile. The DermaV is actually a 1064/532 nanometer wavelength laser. It's two different wavelengths. And those are important because they will treat things of different colors. So even though the laser can be used to treat other conditions in the skin, such as sunspots, we won't really get into that today because we can only focus on rosacea. 

With rosacea, we predominantly use the 532 nanometer wavelength because it has the highest absorption in oxyhemoglobin, which is the red that we see in the blood vessels that cause people to flush, to have the broken blood vessels, to have irritation in the skin, and even the papules or the bumps that we see in rosacea commonly. 

04:57 Trina Renea: So do they have to get numb? Does it hurt when you do it? Are you instantly better with the rosacea? How quickly does it work?

05:07 Dr. James Wang: That's a great question. I think we usually don't numb for the DermaV, although it does feel warm. There's some people who have higher sensitivity. And I think even normal skin and you're being treated with DermaV, you would never need numbing. 

But in people with rosacea, there's already a low-level sensitivity and inflammation in the area. So I do think that no matter what you do to rosacea skin, it just feels more. So we do oftentimes numb people, just for 10 minutes, 15 minutes. It just makes the whole process more comfortable.

But it certainly is more comfortable than prior technologies just on the way the laser is designed and how fast the treatments are. 

05:47 Trina Renea: Do you get swollen after?

05:49 Dr. James Wang: That's actually one of the benefits of the laser is that, yes, you will swell a little bit. But there's actually a setting on the laser. And this is one of the innovations it has is the cryogen cooling. And how that's different is that the older technologies will have longer pulsed cryogen spray in terms of the strength of the spray as well as the length of the spray. And so it's been a lot longer. 

Now, they've divided into kind of three segments. You can control the spray that goes right before the laser is fired to protect the skin and you have a spray afterwards, what we're using to decrease the inflammation, the comfort, as well as the decreased swelling that we see usually 24 hours after a vascular laser is done. 

So the cooling spray is one of the innovations of this device that help make it more comfortable and have even less downtime than usual. 

06:46 Trina Renea: So when can the rosacea seem to be helped or under control if they're— I mean, would they use that laser if they're having a flare up? Or would it be just…

07:01 Dr. James Wang: You can. It depends on what stage we're catching the rosacea in and also the type of rosacea. 

So there's the couple different types. You have the kind they're just like matted broken blood vessels on the face, you have people who only experience intense flushing, you have an ocular form of rosacea, you also have the papular rosacea, which is our little bumps on the nose and on the cheeks. They can all be treated using this device.

And the response time and ____ [07:27] will depend on how severe it is, how long it's been there, what are the triggers for it. And so they all respond but at different rates. 

In general— go ahead. 

07:41 Rebecca Gadberry: I have a friend who was listening to you, I guess, in January on the podcast, and she went to see you and got one of these treatments, and she raved about it. This was about two weeks after she had visited you and she looks so much better. 

07:57 Trina Renea: About rosacea? 

07:58 Rebecca Gadberry: Uh-huh. Yeah.

08:01 Dr. James Wang: Yeah. And, you know, with lasers, and when I give talks and lectures about laser to young dermatologists, I always say, “You know, it's not about memorizing a setting for the lasers, it's not about doing what everyone else is doing. The most important part is really evaluating the skin and just knowing what it is want to treat and how you, as a professional, want to treat that condition.” 

Because there are a lot of subtleties in rosacea that, to the naked eye, you can't really tell. But a careful examination and also a careful history, you'll be able to select the best combinations. 

We, of course, tried to make sure that we minimize the number of sessions required for people, because everyone's busy. No one has time to come back 30 million times to have treatments. We also have to take safety into account. With the technology that we have, we make sure we use the safest technology. That we use the setting which fits with the patient's lifestyle and condition. 

So we take all those factors into account. And I think with your friend who came in, no one ever gets the same treatment. Every time someone comes in, we make adjustments based on how red it is, the distribution, and also their preference. Like, if they have an event to go to in two days, I don't do the same setting as if someone's like, "You know what? I'm going to be working from home for the next two weeks." We take all these into account.

09:27 Trina Renea: Someone was to go to the laser route to treat their rosacea. Could they get it, the laser once a year and it'll help keep it under control or is it something they have to do more frequently?

09:42 Dr. James Wang: It depends. When people come in with active rosacea, which is the case most of the time when they come and see us at our practice, is we usually do a small series, maybe between one and three sessions, what's required to get people to feel not as self-conscious about the redness or the flushing. 

And once they get to the point where they're satisfied with the way their skin looks, then we talk about maintenance schedule. Some people want to come in every three months just because they just want to keep their skin a certain way. And some will come in every six months, once every year. And this will be based on people's budget, it'll be based on people's preferences, and also on how it evolves over time. 

But in my experience, when people get consistent treatment over time, the rosacea actually comes back in longer intervals. As you kind of train the blood vessels not to grow in that particular area, it actually starts to work more effectively over time, assuming they're continuing their sun protection and their standard skin care.

10:45 Rebecca Gadberry: One time I did a little, what's it called, Vbeam, to kill some of the capillaries in my rosacea area, more close to the nose and it burst the capillaries so that they looked purple the next day and bigger and worse. Does the DermaV do that too?

11:07 Dr. James Wang: The DermaV can, but usually it's not required to get results. And that's actually a difference in the way the pulse is delivered. So we try not to burst the blood vessels per se, which is what causes the ecchymosis, the purpura. We actually try to cause some vasospasm, where the vessels kind of die over time and your body reabsorbs it. That's a way that decreases downtime.

But both methods work. I used to use it a lot. I still think that’s a great laser. Nothing wrong with the Vbeam or PDL laser. There's some kind of more logistical issues with using those devices. They're a little less stable in terms of the reliability of those devices because they can break a little bit more easily.

But certainly, you can achieve results for telangiectasias using both devices. But we never had to cause purpura for telangiectasia or rosacea. So the downtime really is minimal. You're really just pink for about 24 hours on average. 

12:11 Trina Renea: Okay. That's good. 

12:12 Dr. Vicki Rapaport: I have a question just about dermatologists and why some people are very laser oriented and why some aren't. One of my hesitations always was that there's always going to be a newer, better machine out there. So I was always so hesitant to buy a machine. 

Of course, I found some that I do love and I have kept them for many, many years, but PDL or Vbeam at the 585/595 nanometer wavelengths versus the 532, you're saying now that 532 is the best way to absorb the oxyhemoglobin. How come they didn't know that 15 years ago? Aren't these easy studies to do? Like what absorbs red light the fastest, the best? And then why did they create lasers that weren't as good and now they're making them better? It's so frustrating for a dermatologist. Like, all of a sudden this one's better. They know this information. 

13:02 Julie Falls: It's obsolete.

13:04 Trina Renea: That's like Apple coming out with their phones. 

13:05 Julie Falls: Exactly. New chargers for your iPhone. 

13:10 Dr. James Wang: It's such a good point because, actually, so right now I'm at the ASLMS meeting, which is the American Society for Laser Medicine annual meeting, and this is discussed all the time, even among the leaders in laser technology. It's not that people didn't know 532 nanometers was the best wavelength because the absorption is the best at 532, not 595. 

However, there is no safe way prior to deliver an adequate pulse of 532 that does not cause heating of the skin to the point where you actually cause the post-inflammatory pigmentation because a high absorption of 532 is melanin. And when you treat vascularity, you do not want to treat the melanin because it will cause that pigmentation to happen at the same time you treat the blood vessels. So that is not a very good option at that time. 

But now, the way that the pulse is structured, which I'll talk about in a second, as well as the way that the cooling is so much more efficient with the post-cooling as well, it makes it possible now to reach an energy where you can destroy the blood vessels and at the same time cool the skin enough where it does not attack where the pigment is sitting, which is the dermal-epidermal junction of the skin. That's the danger zone for everyone. 

But the pulse structure you bring up is really unique. The DermaV is what I consider really three vascular lasers in one device. I say that just as a dumbed down version of the laser because it's more than that. But it has three specific features that make it unique. 

There's one feature that can mimic a Vbeam or PDL exactly. And we call that the millisecond pulse, sub-millisecond pulse structure. What that is is when you fire a Vbeam or PDL laser, and you put 10 milliseconds on there as the pulse duration, you're not getting a continuous 10 seconds. You're actually getting four or five pulses that add up to 10 seconds. So that's the pulse structure of a Vbeam and PDL. 

Now, lasers like Excel V, another common device on the market, is a 532 but it's continuous, meaning when you put 10 seconds in, it goes all the way through. It's a single pulse without any little sub-segmentation of the pulse.

DermaV can also do that, if you'd like, and there's a time and a place for each one of those pulse structures. But on top of that now, they actually have something called sub-micro, and sub-micro is truly unique because it can actually get rid of the tiny, tiny little blood vessels that are present in red scars as well as in the vessels that cause people to have that light background pink and the sensation of flushing on the surface of the skin. 

That is truly a new feature where it's no longer just cosmetic, it's also a symptomatic improvement in people who feel hot in the face when they're embarrassed or when they drink or they are exercising. So that's a big deal into changing people's quality of life earlier on.

16:21 Trina Renea: So then this is the best laser to treat the skin now. So if you do DermaV, it can't really get much better. But will they come out with another laser again in five years that's going to be even better than that? I mean, you just…

16:41 Dr. James Wang: Well, I really hope so. I always hope that they come out with better things, right? It's a work in progress because there are the studies that laser companies do that tell people, “Oh, this is great.” But in the end, it takes enough dermatologists to do these things to actually give important clinical endpoints. 

When a laser comes out, the settings that people use aren't necessarily the right ones. And so it really takes a panel or group of experts over time to hone those settings to the point where we're getting consistently great results. 

And so, sure, maybe in five years we have another revolutionary change, but that's five years’ worth of patience. That's a lot of patience. 

17:26 Dr. Vicki Rapaport: And also, it gets better for the patients. It's not better for the dermatologist, which is fine. But it's safe. It's more effective.

17:31 Trina Renea: Yeah. They should have a buyback thing for the dermatologist. You can turn in your old machine for the new. 

17:38 Dr. Vicki Rapaport: If you stick with the same company, they will often do a trade-in, but they want you to stick with their company. But it is safer and more effective, eventually, for the patients, which is great. 

17:49 Dr. James Wang: Yeah. I think it's nothing wrong with a Vbeam. And I always say this as like, if something's working really well for people, that's great. There's no real need to change a laser. But if you feel like there are areas or some difficulty treating certain things that you see often, that's what I think is the best time to think about a change, because you certainly don't need something that's powerful if you're not seeing those patients on a daily basis.

Now, actually, many spas and different practice settings, there may be no need to treat severe, severe rosacea. You may want to send those patients to dermatologists to treat it. And as a dermatology practice where we see a lot of vascular lesions, some quite difficult to treat, especially the birthmarks, then sometimes having a more powerful laser is necessary. 

And I wouldn't be saying it's revolutionary if I really didn't think that to be the case. Laser companies make incremental changes to technology over time, which is fine, but this one really adds a new dimension to the laser, and so it really does expand its uses in this clinically significant way.

I think in dermatology, it always takes time to adopt new technologies, which is not a bad thing. I think there needs to be a caution and a safety when something new comes out. But even places like Mass General and big academic institutions are seeing the benefits of this. I talked to a lot of people this weekend, actually, as some of these institutions that are really, really excited about the way they're going to use DermaV not just to treat kind of higher practice dermatology issues, like rosacea and acne scarring and other things, but also to treat really difficult advanced birthmarks that have been resistant to past treatments using the PBL or Vbeam lasers.

19:44 Dr. Vicki Rapaport: Amazing.

19:46 Trina Renea: How much is a DermaV treatment?

19:51 Dr. James Wang: It depends. I always say that it's where you are in the country, your population, how long it takes you to do the laser, how your clinic is set up, but, in the end, I think every place has to price it. In my experience, people price it in between $400 to $700 is kind of the range that people can price these, the sides of the area you're treating, and who's doing the treatment as well. That will change the pricing structure. 

20:20 Trina Renea: Okay, so under a thousand for a treatment.

20:23 Dr. James Wang: I think so. And someone's charging over a thousand for this. There may be a good reason why, but I tend to like to keep it reasonable where people, if they need a couple of treatments, it's still affordable. You don't want to kind of run out of steam after the first session because you can't do more. 

And that's something that, in our evaluation and in our consultations, we always talk about. I think, oftentimes, people shy away from talking about finances, but I certainly think it's a really important thing to know right off the bat. Because how can you create a full plan if you don't know how many sessions someone can do? 

And maybe I'll choose a different technology, maybe not quite as aggressive or powerful in the very first session. But I know that if they're able to afford three to four of those sessions in this cycle, they'll get a better result. 

21:07 Julie Falls: I have to say that I myself have had this treatment several times with Dr. Wang. As a result, my broken capillaries and some of my rosacea next to my nose and my chin has diminished so much. I can now say that I'm not using any of my rosacea medications. 

21:32 Trina Renea: Wow! And it's winter. 

21:36 Julie Falls: And I barely need to cover my face with anything, except maybe a tinted moisturizer. 

21:42 Trina Renea: How many times in a year have you done it? 

21:45 Julie Falls: I did it, I would say, over the past two years I did it three times total. So maybe two this year, one last. 

21:54 Trina Renea: And so it's sustaining your rosacea so that you're not getting so much flare up. 

22:00 Julie Falls: Correct. 

22:01 Trina Renea: And it's less red. 

22:03 Julie Falls: Yeah. I went to see him for something else and he looked at me and he said, "All I see right now is red.’

22:11 Trina Renea: You’re so mean.

22:12 Julie Falls: “So let's address that.” And I said, "Okay. You go. Whatever you want to do to me." 

22:18 Dr. James Wang: Wow! Thanks for making it look so bad, Julie. I appreciate that. 

22:21 Julie Falls: No, I like that direct approach. Are you kidding? I don't want my doctors pussyfooting around, right?

22:27 Dr. James Wang: No, no. I'm joking. I get it. 

22:29 Julie Falls: No, but I mean, layering on some of these medications year after year and starting and stopping and starting, and some people are getting, and I did for a while get very good results from the medications. And then I was like, “These aren't working anymore for me.”

22:47 Trina Renea: Yeah. It was nice to know that lasers are out there in the world for people who can afford them.

22:59 Dr. James Wang: Yes, absolutely, lasers are not cheap and your laser devices are very expensive as well as the maintenance, and also the expertise required, but I do think it's important for people to know that, yes, topical options can be helpful, oral options can be helpful, but there's also a new generation of devices that can also help as well. Just so people have all the information, right? 

And then whether they do a laser or not is completely dependent on their ability to assess their own life circumstances and make that they should further themselves. It's not to me to limit people's knowledge or the potential. It's up to them to figure out what they want to do. So everything is about a choice. 

23:36 Julie Falls: When you add up medications year after year after year, that's going to add up too. 

23:39 Dr. Vicki Rapaport: Yeah, I was going to say that.

23:40 Julie Falls: Thank you. 

23:43 Trina Renea: So Dr. Wang, we're going to close this episode with a question. This has nothing to do with rosacea, but we do a question that's trending or from a listener. 

So, there is a new device out on the market called Ellacor. I know that you got an opportunity to see it live and in person last week. And so, can you tell us what it is? Because I know that I've seen stuff on it and it looks really crazy to me, because they're taking, basically, like a thousand punch biopsies all over your face. Like you said, like a sewing machine across the face, just pulling out tons of skin. What is this barbaric-sounding machine? 

24:43 Rebecca Gadberry: That's an unbiased statement.

24:45 Trina Renea: Sorry, that's my opinion. 

24:48 Dr. James Wang: I just want to say the caveat is that, of course, I do not have an Ellacor device and I have not used it on a patient. I have had the chance to fire the device and understand a little bit on the theoretical aspect of it. 

I do think there's a use for it. I do think, in general, the concept of the punch biopsy is not new in the face. When people have ice pick scars or certain types of just difficult to treat lesions, dermatologists traditionally have done these little mini punch biopsies in the face to try to have those lift up when they heal. So that's not a new concept. 

The early iterations of this device really was punch biopsy-like. So half-a-millimeter punch biopsies, which leads to scar tissue. It leads to scars. The Ellacor has been approved. It's actually a much smaller diameter. It's equivalent to a 23-gauge needle. That's what each core's diameter is. 

25:48 Dr. Vicki Rapaport: It's tiny. 

25:50 Dr. James Wang: It's tiny, right? And so, sure, if you did a bigger punch, you would have more collagen generated, but it's unsafe. So it is small enough where, if you do it correctly, it's meant to tighten, it's meant to decrease the acne scars. It can be used probably off the face, which I think currently is not FDA approved, but certainly people kind of experiment on these types of things. 

In my experience, when I've seen the treatment done, it is something that requires either a nerve block or tumescent numbing. So it's needle-based numbing under the skin because it is really painful without numbing. Topical numbing is just insufficient.

And it does sound like a sewing machine. It does little squares and it's, I agree, it looks a little gruesome. It is quite bloody. It's almost between like what a general dermatology and a plastic surgeon would do in it's still not fully invasive, but we still consider it minimally invasive. 

But, certainly, when you're coring out little pieces of skin, you're going to bleed. The bleeding takes about five minutes to stop and people have to do a wipe down afterwards to make sure that the cores are removed from the skin so the new collagen regenerates. 

I think there's a lot of potential for potentially tightening the area around the jowl area, which I know a lot of people have concerns with. If they feel like other devices aren't quite getting them to their endpoint, I think there's a use for it. I think it probably takes still a couple of sessions to get you improvement there. But of course…

27:33 Trina Renea: But then there's going to be some scar tissue, I would imagine, that's forming. And then if you punch it again on another treatment and you punch into the scar, I don't know, it seems messy. Like, I don't know smooth-wise…

27:46 Dr. James Wang: Not everyone's going to want to do this, right? Not everyone's going to want to do this. Not everyone’s going to deal with a downtime. It's not for everyone. 

27:52 Trina Renea: What about keloiding?

27:58 Dr. James Wang: They didn't see any in their studies. I think it remains to be determined in the real world, what we see with Ellacor. There are some users of Ellacor, the early adopters of the technology. I think it's a good technology. I think that, theoretically, it's actually really good. I think my main concern is that it requires operator precision.

Some devices are made where it's really easy to use and it's hard to make a “mistake.” But this device, if you accidentally overlap two sets of holes, you will get a scar. 

28:35 Trina Renea: Oh, God. How can you not? How can you not overlap?

28:44 Dr. James Wang: There are some built-in safety features where there is a low-level suction which sucks the skin up against the plate where it happens so it keeps the skin in place. But it is something that requires two people in the room, one being a medical assistant that can stretch the skin for you as you do it. 

So it is not a simple five-minute procedure. I would say it probably takes about 30 minutes to 45 minutes to do well. And then the person doing it can't go too fast. It needs to be done where you're spacing these things out appropriately. You've never want to overlap the holes. 

So they are still working on the device in terms of new areas, new indications, safety profile. I think we'll all need devices undergo this process, but, certainly, it's a class by itself. There's not much before that's doing what it's doing and so I think it remains to be seen how much people like it. 

I know it's probably going to work. Certainly, when you remove a lot of skin like that, you're going to get some volumization, a ton of collagen generation. The question remains to be seen as what are the complications and is that an acceptable rate and result for a small subset of people who actually get the complications. 

30:01 Trina Renea: And possibly pigmentation I would worry about as well. 

30:06 Dr. James Wang: And pigmentation has been seen in the studies, but those did go away over the course of two to four weeks, usually. 

30:13 Dr. Vicki Rapaport: - Well, also, if you look at all the before-and-afters, everybody is skin type 2 or 3, Trina. Nobody is like a darker skin type, because it's really not appropriate for those people with hyperpigmentation. 

30:22 Trina Renea: Yeah.

30:24 Dr. James Wang: It's 1 through 4, they say, I think 4, I would be nervous to do on skin type 4 on myself, especially in the beginning. I'm sure in the hands of people who have used Ellacor over time, it's safer in their hands. But, certainly, I would hesitate to use this when you first use the device. 

30:47 Trina Renea: Okay. Well, thanks for sharing that. I just wanted to talk about it for a quick second, let people know that it's out there and watch out. Watch out.

30:59 Dr. James Wang: No, I don't want to say that. It's a good technology. I'm always on the cautious side.

31:05 Julie Falls: Yes, do your homework. 

31:06 Dr. James Wang: I think, as we get more info, and look, we may have this discussion next year and we’d have a very, very different opinion of it once we know what people are getting and the results that we're getting. 

I'm still very excited about a technology like this. I'm just also very cautious of the potential for complications in the wrong hands. 

31:24 Julie Falls: Yeah, sure. I mean, once upon a time, even like micro-needling, we were like, "What?" Things come up and they're more and more powerful , but I think, well, maybe that'll be my takeaway, but I think that proceed with caution with everything. That's why we have our experts on here to guide us. 

31:46 Trina Renea: All right. So we're going to wrap up this rosacea laser episode. Thank you for joining us, Dr. Wang, and we'll be back with you on some more lasers later this month. I'm very excited to talk about a couple of them, the Alma Hybrid, I'm really excited to hear about that. 

So, we will see you again soon. Thank you.

32:12 Dr. James Wang: Thank you so much. 

32:12 Dr. Vicki Rapaport: Thanks, Dr. Wang. Your always awesome. 

32:13 Dr. James Wang: - Thank you. All right. 

32:15 Trina Renea: Thank you. 

32:16 Dr. James Wang: Thank you.

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