This post is sponsored by Candela Medical.
I’m so often asked really specific questions about the skin that I, as an educated consumer and by no means an expert, ethically cannot answer. Armed with this and a wish to still offer Glow Journal readers and listeners some real value, I took the idea of an Ask The Expert series to the team at Candela Medical knowing that both the technology and the doctors they work with are among the best in the world.
Today, we launch a multi-part series of bonus interviews to answer your questions. This series is giving the Glow Journal audience unprecedented access to medical doctors, professors and dermatologists- professionals with an unparalleled understanding of the skin. While the series is sponsored by Candela, doctors legally and ethically have to remain completely objective in interviews like this. For this reason, this series feels like the most authentic way for me to integrate branded content into the podcast because it’s giving you, the audience, unbiased, expert answers to your questions.
We begin this series with Associate Professor Philip Bekhor- the first dermatologist in Victoria to use lasers in the management of birthmarks, the Director of the Laser Unit at the Royal Children’s Hospital and the founder of Laser Dermatology- in conversation with me, as I ask him YOUR questions on rosacea, spider veins, dark circles, burst capillaries and related vascular skin conditions.
The following is an excerpt from the Glow Journal podcast. To listen to the full interview, subscribe now on iTunes or Spotify
GLOW JOURNAL: I’m going to start with rosacea, as I understand that about 30% of the population suffer from a form of it. What is rosacea?
ASSOC. PROF. PHILIP BEKHOR: It’s an extremely common condition and a lot of people [reading] this actually have it and haven’t realised. In the simplest form of rosacea, which we call erythematotelangiectatic rosacea, it means redness, a tendency to developing broken capillaries, sensitive skin and easing flushing. This sensitivity is due to the fact that the barrier in the skin is weak. Chemicals that normally should be harmless in soap and perfumes go through the skin and irritate it. So basically, [rosacea] is redness, sensitive skin and easy flushing. That’s the basic, extremely common form of rosacea.
In some individuals, it goes further than that. It forms a condition that we used to call ‘acne rosacea’, meaning you get pimple-like lesions. ‘Normal’ acne will mean blackheads and pimples, whereas in the acne type of rosacea, which we call papular rosacea, they’re more like little blind pimples and bumps. They’re often quite tender. They’re not always there- they come and go. The attacks can be induced if you drink too much red wine, get sunburnt, or do anything that makes you prolongedly red.
You’ve touched on how there are some things that we might put on the skin or ingest that can cause a flare up. Other than cutting those things out, can laser help rosacea as well?
The treatment involves, firstly, avoiding the triggers that cause flushing. However, it’s not enough for many people to just avoid these things. They actually need further treatment.
For the erythematotelangiectatic rosacea or just red, sensitive skin, lasers can be very helpful. I personally use the Candela V Beam system, which seems to be very safe and very helpful to reduce the skin sensitivity and try to move it away from the rosacea state to a more normal state with a better barrier function. It’s definitely very powerful to get rid of broken capillaries, and a lot of people, after a laser treatment, find the skin is less irritable and doesn’t flush as easily.
How many treatments would you recommend people come back for? Or are the results immediate?
Typically, it depends on what stage we’re treating. If we’re treating young people who don’t have broken capillaries, they might just do one or two treatments a year to maintain the improvement. We’re not curing it, but we’re controlling it. After a period of time, the effective laser can wear off and often it needs to be done again.
However, a lot of people have ignored it- a lot of women who have the luxury of using makeup to cover it. If they decide that they’re just needing too much makeup, and they’re getting big, roadmap type blood vessels on their nose, then laser is fantastic for that. It’s highly effective to get rid of these vessels, but it does take more treatment. Phase one is getting rid of the broken capillaries, which might take two or three sessions. Once we’ve got all of that redness off, we do background redness flushing treatments on an annual basis.
So the key is to come in as soon as you start to notice something?
I believe so. For one, to learn what is appropriate skincare, and two, to nip it in the bud and prevent the development of broken capillaries, and then to change your lifestyle a little bit to try to reduce those triggers- the worst trigger, of course, being alcohol. Some people are more susceptible to alcohol than others. There’s an enzyme that breaks down alcohol and some people just break it down in a weird way. They only need almost two mouthfuls of wine and they’re red. So you’ve got to look at your pattern, modify what you drink and how much you drink to control it.
But we only live once! I’m not saying that we shouldn’t have fun, but we can work out how to temper it.
That’s such good advice because with skin conditions like that, I understand that going to see a dermatologist or a dermal clinician is an expense, but then they’re the experts and they’re going to send you off with tools and information about your skin that you can take with you.
I completely agree. It’s an evolving area. Dermatology is very much increasingly focused on this kind of problem, and over the years new treatments are going to become available. In one year it will be different, so it’s always worth keeping in touch and finding out what’s new.
The beauty of technology! Something that I get asked quite a lot, a very broad question- Is laser safe? I think some people are scared that their skin’s going to react to laser in the same way that it would react to the sun and to UV.
I was one of the first people in Australia to use lasers on the skin, so this sort of question is a routine one that we have to answer.
It’s complicated, because light is a form of electromagnetic energy, but so is x-ray and ultraviolet rays. What we understand is that x-rays and ultraviolet rays interact with our chromosomes and mutate them, and that sets you up for cancer. The laser is just visible light. It’s the same light that comes out of a light globe. It doesn’t have ultraviolet or gamma radiation in it. It doesn’t damage the chromosomes, so we do not believe that it has a precancerous effect.
Another way of looking at it- people in Norway, where there’s very little sun, have a lot of exposure to just the natural light induced by light sources and they get much less skin cancer than people who have sun exposure.
In summary, laser light is not precancerous light. It lives in the realm of visible light. Some of the lasers use the invisible infrared light, which is essentially just heat, neither of which are potent inducers of skin cancer.
Let’s move on to spider veins and varicose veins. They are so often put into the same category, but am I right in saying that they are two different things?
We’ve been talking about the face. Let’s move down to the leg.
As a general principle we’re talking about capillaries on the face, but the legs they’re essentially disorders of veins. You get super big veins under the skin [on the legs] and when they are disturbed, they swell and become bulgy, under the skin lumps. The treatment for that is not going to be skin-applied laser, because laser is not an x-ray- it’s just light, it can’t penetrate that deeply.
The treatment has to be directed to veins. Sometimes lasers are used, but they are lasers that are inserted into the vein. There’s different ways- there’s chemicals, and even surgery to switch those veins off.
Then you can get disorder of the surface- tiny veins that actually are in the skin, removing the blood in the skin, and these can become disturbed. These can be variable blue things like biro marks on your skin and sometimes finer vessels. The basic treatment of the surface [disturbed veins] is probably injecting with solutions that close the vessels.
Laser is also effective in this space. The treatment will often involve a combination of both. For those people who just don’t like the idea of needles, it doesn’t hurt to try the laser based methods first.
At the core of it, what is the difference between spider veins and varicose veins?
Varicose veins are disorders of the big veins under the skin. Spider veins are disorders of the tiny veins we call venules within the skin itself.
You’ve mentioned that a combination of treatments is often the most effective. Naturally, with something like a surgery, there is going to be downtime. Is there downtime if people choose to just go with the laser option?
It’s what I call cosmetic downtime. This means that after we block up the veins they actually look darker and worse for a period of time, so it’s not the sort of thing you’d want to do before a summer holiday. The laser treatments have the advantage of not requiring compressive stockings, whereas when we do the injections I certainly recommend a week of 24/7 compressive garments and graduated compression stockings, which a lot of people find inconvenient because you have to keep these dry in the shower.
I’ve had a listener write in saying that she’s had varicose veins removed, but they keep coming back. What would be the reason for that?
There’s two possibilities for a question like that. Varicose veins and surface veins are not directly related, so the first possibility is that sometimes after surgery for varicose veins, which fixes all the deep stuff, you can actually get a worsening of the surface spider veins. That’s the possibility. The trouble with these spider vines is that we don’t really cure them. We get rid of them by whatever method we use, but then as you age, more will develop, and a maintenance program is necessary.
The other possibility. Let’s say she’s telling us that her full-on varicose veins are coming back. That means that the valves that weren’t working were fixed, but then other valves that are malfunctional are sending blood into the area. Typically it means they fixed up the veins in the legs, but some women have damaged valves in the pelvic area post-pregnancy, and that blood can sometimes get into the legs and keep those veins swollen.
I have had another listener write in saying that she’s been told she has troubles with lymphatic drainage and that this is going to make it harder to treat things like spider veins and varicose veins. What is the link there?
I don’t think there’s a direct link. They’re different systems- the lymphatic system just removes fluid from the legs. If you’ve got a really bad malfunctioning venous system, with what we call increased venous pressure in the leg, you will collect more fluid and that can cause swelling. That’s fixable by varicose vein work, but if it’s purely lymphatic, fixing veins won’t make any difference.
I know we’ve said we’re moving down the body, but I’m going to bring it back up to the face. Let’s talk a bit about facial veins and burst capillaries. What causes them?
There can be a number of causes. I think a lot of it is just a hereditary predisposition. Some people, as they age, develop these veins. Traumas like repeated sunburn can induce vessels. We’ve talked about rosacea, and those people with a tendency to rosacea that then have another injury are going to be far worse.
I see a lot of people asking for treatment for bulgy veins around their eyes that make them look tired. There’s no reason for these, other than a hereditary predisposition. A lot of my patients tell me that their mum or dad had similar vein issues.
Given that it really is hereditary, is there anything that we can do to minimise our chances of having visible broken capillaries?
With broken capillaries, yes. If we go back to the triggers, if we’ve got a family predisposition to rosacea and we avoid the flushing triggers, we can slow the development of these. If it’s other kinds of hereditary things, like a tendency to bulgy veins, I don’t think there’s anything that you can do to stop them.
If we do have them, what would be the best course of action?
If you can see the vein, meaning it’s superficial enough to see the vessel or see the colour, then that is in the range in which visible light can penetrate. I’m really very confident that most of these problems I can fix with the laser systems that I have.
This is something that you have just touched on, but I have had a few really specific questions about dark circles under the eyes. Of course, that is often hereditary, but is that related to our veins?
Dark circles under the eyes are very, very complex because there’s a lot of different causes.
In the Caucasian group, the most common is super thin skin, so you’re seeing through the skin to see muscle and the little vessels. Sometimes we can help that with a little bit of general vascular laser that might reduce some of the stretch vessels there, but it’s a marginal benefit. The other problem with these kind of very weak skin is that it can often be associated with weakness of the membranes that hold the eyeball fat back. A lot of people with this tendency, as they get older, get that kind of pouchy bulging under the eye, for which the solution is going to be plastic surgery or oculoplastic surgery.
If we were to take the laser course of action, is there a specific treatment that you would recommend?
I think that gentle V beam vascular laser can often help a little, and it has the tremendous advantage of it either helps or doesn’t help- it’s not going to make it worse.
I’ve talked about the group with the thinner skin, and then you have another group where it’s actually pigmentation. It’s very common in darker skinned people, to have increased pigment around the eyes. Thats’s where we would use laser.
Is that permanent?
If they will respond to laser, the treatment should be permanent.
And does this fall under that cosmetic downtime category that you talked about?
Yes, but not so severe. Generally you’d expect some redness and swelling.
Port wine stains. Let’s talk about them. This is an area that I’m so unfamiliar with.
A port wine stain is a birthmark. It means that they’ve got a red area on the skin. They’re present at birth, persist through life, but unfortunately as one gets into adulthood, sometimes the veins thicken and they go from a pink colour to a bluish colour. Sometimes, in rare cases, they’re associated with underlying abnormalities.
Bottom line is that the Candela pulsed dye laser system revolutionised our capacity to treat these port wine stains. We now like to treat as soon as we can in early infancy and, as an average, I would say we can get 80% of these 50% lighter. Some of them almost disappear completely, but most of them can be improved to some extent.
This is such a broad question, but why do port wine stains occur?
That’s a good question. If you asked me five years ago, I wouldn’t have been able to answer, but a lot of research is now looking at genetic mutations. The original concept was that you had a bad gene- you inherited it and you got it. But we’re now learning that they are what we call germline mutations meaning the mutations are going to be in the ovary or the sperm. We’re understanding that in the process of foetal development, a little area where two cells divide gets a mutation, so it’s not a mutation you inherit, but the mutation will affect that zone of the skin that develops from those two bad cells. Typically, if you have a port wine stain on the face, a cell misbehaved and all the daughter cells that cover that particular region of the face have this genetic mutation. We now understand that it’s a genetic mutation that occurs in the process of building the body as a foetus. What we’re hoping is that, eventually, we will have medical treatments to intervene and modify this malfunctioning gene- but at the moment, we can’t do that. What we do is use laser to treat the damaged vessels and get them replaced by more normal blood vessels.
Could you talk a bit about the difference between the way that you would treat an infant who has been born with a port wine stain, as opposed to say an adult who has left it untreated and then, later in life, has decided they want to work on them?
We’ve found that under six months of age, babies do not remember pain and cope very well with treatment without general anaesthetic. We want to get these babies early and use that amazing window where we can treat without GA. From six months when they start to develop memory, you can’t do it. They’re going to be anxious and they’ll be traumatised, so generally they’ll need to be anaesthetised while we do it.
When we move into the adults, say post 16, 17 or 18 [years of age], we start to be able to treat again without general anaesthetic. Modern lasers give us choices in terms of the depth that the laser will go. The process where the pink port wine turns into a blue port wine stain represents deeper vessels becoming abnormal. In a child, it’s all pink on the surface, and we can use Candela V beam [laser], which is a superficial, highly absorbed into blood vessel laser. When we’re treating adults, we have to pick wavelengths that go more deeply. We might use an IPL system- the one I liked is called Nordlys, or we might use Alexandrite laser or long pulse YAG laser. These lasers will go deeper. If it’s the pink component, we need a superficial laser, and if it’s a deeper component we need wavelengths of light that will go more deeply into the skin.
And are those treatments permanent? Does how effective they are depend on age and when you’re treating the port wine stain?
In children, I think about 70% of the improvements remain. There’s another group of 30% that we treat, and then over a three or four year period or so, they re-darken. A percentage of patients need maintenance. We don’t have a test yet to work out what the difference is between the ones that recur and the ones that remain permanently better.
Well, based on how quickly, everything changes, we couldn’t have an answer to that soon!
Interview me next year and I might have an answer!
