Laser and Skin

Couperose and rosacea: a difference with consequences

Couperose is what you see: dilated vessels of 0.1 to 1 millimetre and a persistent redness on the cheeks, nose and chin. Rosacea is the chronic inflammatory condition that usually sits behind it, affects around 5% of adults and runs in flares over years. A vascular laser or intense pulsed light clears 50 to 75% of visible vessels in 1 to 3 sessions and the result holds for about 3 to 5 years, but the condition itself is managed with medication and trigger control, and that second part decides how soon new vessels appear.

Two words that describe different things

Couperose is a word from the cosmetic vocabulary of continental Europe. In an English-speaking clinic the same finding is called facial telangiectasia or, colloquially, broken capillaries: dilated vessels 0.1 to 1 millimetre wide that shine red or bluish through the skin of the cheeks, the sides of the nose and the chin, usually on a background of persistent redness. The vessels are not broken. They are permanently widened, and once widened they do not close on their own.

Rosacea is a diagnosis. It is a chronic inflammatory condition of the central face that affects around 5% of adults worldwide, starts most often between 30 and 60, is diagnosed more often in women and tends to run more severely in men. It comes and goes in flares, and over the years it can add papules and pustules, thickened skin on the nose and, in more than half of patients, dry, gritty or inflamed eyes.

Since 2017 dermatologists no longer sort rosacea into the 4 subtypes of the 2002 classification. The global ROSCO panel, 19 dermatologists and 2 ophthalmologists in its 2019 update, describes the condition by features instead: 2 diagnostic features (persistent centrofacial redness that intensifies with triggers, and phymatous thickening), 3 major features (flushing, papules and pustules, telangiectases) and minor features such as burning, stinging, dryness and swelling. One diagnostic feature or two major features make the diagnosis. Visible vessels are therefore one feature of rosacea, not the disease itself, and a face with a few vessels after decades of sun, wind and cold may have no rosacea at all.

Why the difference changes the treatment

The consequence is practical. A vessel is a structure and can be destroyed; inflammation is a process and has to be controlled. Treat only the vessels and the process keeps producing new ones; treat only the process and the vessels that already exist stay where they are. Most people with couperose on a rosacea background need both, in that order of importance: the condition first, the cosmetic result second.

The confusion with acne costs the most time. Rosacea papules look like spots, but there are no blackheads or whiteheads, and the usual acne actives (benzoyl peroxide, high-strength retinoids, alcohol-based toners) sting and redden rosacea skin. People who self-treat for months with acne products often arrive at the dermatologist with a worse picture than they started with. See acne: four causes, one plan for what real acne needs.

Eye symptoms are the second reason to see a doctor rather than a salon. Rosacea affects the eyelids and the surface of the eye in over 50% of patients; a painful or red eye, blurred vision or sensitivity to light call for a same-day appointment, because keratitis can damage sight.

What the vascular laser does, and for how long

Vascular lasers and intense pulsed light (IPL) work on one principle: haemoglobin absorbs light strongly at 532 and 595 nanometres and, less strongly, at 1064 nanometres. The pulse heats the blood inside the vessel, the wall coagulates and the body clears the sealed vessel over the following 2 to 6 weeks. The pulsed dye laser at 595 nanometres and the KTP laser at 532 nanometres are the standard tools for fine facial vessels; the long-pulsed Nd:YAG at 1064 nanometres reaches deeper, bluish vessels; IPL uses a filtered band of roughly 500 to 1,200 nanometres and covers diffuse redness across a whole cheek.

The figures the AAD gives its patients are sober: most people see a 50 to 75% reduction in visible vessels after 1 to 3 treatments, some 100%; redness, on the other hand, drops by only about 20%. Sessions are spaced 3 to 4 weeks apart. Treated vessels do not reappear, but new ones form, so results on vessels tend to last 3 to 5 years before a touch-up. The 2019 systematic review of 152 rosacea studies with 20,944 participants rates the evidence that pulsed dye laser, Nd:YAG and IPL reduce redness and above all telangiectasia as low to moderate certainty, which means the effect is real but the trials are small.

After a pulsed dye laser session the skin is red for up to 2 weeks and may show purple spots that clear in 1 to 2 weeks; IPL usually causes less bruising and slightly more discomfort during the pulse. Darker skin phototypes need lower settings and an experienced operator, because the same wavelengths are absorbed by melanin. The AAD advises a board-certified dermatologist, and several countries reserve vascular laser work for physicians by law; Germany, for example, has done so since 31 December 2020. Expect roughly 200 to 500 EUR or 250 to 600 USD per session and no cover from health insurance. Vessels on the legs follow other rules, see spider veins.

Managing the condition behind the vessels

The ROSCO panel set the goal at clear skin rather than almost clear, because complete clearance lengthens the time to the next flare, and it agreed with 21 of 21 votes that rosacea is a chronic disease that needs long-term management. Medication is chosen by feature. For persistent redness, topical brimonidine produced a two-grade improvement in 114 of 277 patients against 54 of 276 on vehicle, measured 3 hours after application; the effect lasts about 12 hours and a few patients see rebound redness.

For papules and pustules, azelaic acid (15 or 20%) improved 648 of 1,132 patients against 439 of 1,091 on vehicle; ivermectin 1% cream gave good or excellent improvement in 615 of 910 against 169 of 461; metronidazole at 0.75 to 1% improved 94 of 195 against 40 of 139 and remains the cheap standard. Oral doxycycline at a 40 milligram modified-release dose cleared or almost cleared 91 of 353 patients against 53 of 354 on placebo; the NHS gives antibiotic courses of 6 to 16 weeks. Low-dose isotretinoin, around 0.25 milligrams per kilogram, is kept for cases that resist everything else, reduced lesions by 90% in 62 of 108 patients against 5 of 48 on placebo, and is never taken during pregnancy or without reliable contraception, because it damages a developing baby.

Two timing rules save frustration. Topical treatments need 8 to 12 weeks before you can judge them, and lasers are timed for a quiet phase: a flare with active pustules is treated with medication first, the vessels 4 to 8 weeks later. Many clinics combine both within the same year, which the ROSCO panel supports for people with several features. An overview of the other red marks a laser can and cannot treat is in vascular lesions.

Triggers, sun and skin care you control yourself

Rosacea reacts to anything that pushes blood into the face. The NHS list reads: alcohol, spicy food, hot drinks, sunlight, heat and cold, aerobic exercise and stress; the AAD adds wind, some skin and hair products and certain medicines. Not everyone reacts to everything. The diary the National Rosacea Society recommends is filled in daily for at least 2 weeks; 4 to 6 weeks catches seasonal patterns and gives you a personal list rather than a general ban.

UV light is the most significant environmental trigger, and daily sunscreen with SPF 30 or higher is the one measure every guideline shares. Mineral filters with zinc oxide or titanium dioxide are tolerated better than chemical filters by many rosacea patients, and they also block part of the visible light. In cold wind a scarf over the cheeks and 5 minutes of cooling down before you step into a heated room reduce the flush.

Skin care follows the rule of less. Lukewarm water, a soap-free cleanser, patting instead of rubbing, a fragrance-free moisturiser twice a day and no exfoliants, scrubs or alcohol-based toners. Azelaic acid and niacinamide are usually tolerated; retinoids and fruit acids above about 5% often are not. Test any new product on a 2 centimetre patch behind the ear for 7 days before it goes on the face, and never use a topical steroid on rosacea skin without a prescription, because it aggravates the condition once the steroid stops. The Ingredient Decoder helps you spot fragrance and alcohol on a label before you buy.

Questions to ask before you book a vascular laser

Frequently asked

Is couperose the same as rosacea?

No. Couperose describes visible dilated vessels and persistent redness on the face, a sign that can stand alone after years of sun and cold. Rosacea is the chronic inflammatory condition that produces those vessels in most cases and adds flushing, papules, pustules and eye symptoms over time.

How many laser sessions does couperose need?

Usually 1 to 3, spaced 3 to 4 weeks apart. Most patients see 50 to 75% fewer visible vessels, some 100%, and a treated vessel does not come back, although new ones can form and a touch-up after 3 to 5 years is common.

Does the laser cure rosacea?

No. It removes vessels and lowers redness by about 20%, but the inflammation continues, so papules, flushing and eye symptoms are managed with topical or oral medication and trigger control. Treat the condition first and the vessels second, and the laser result lasts longer.

Can a beauty salon laser the vessels on my face?

In many countries the treatment of vascular lesions is reserved for physicians, in Germany for instance since 31 December 2020, and the AAD advises a board-certified dermatologist because the result depends on the operator. A salon can help with skin care and trigger advice, not with the laser.

Why do my acne products make the redness worse?

Because rosacea is not acne. The papules look alike, but rosacea has no blackheads, and benzoyl peroxide, strong retinoids and alcohol-based toners irritate reactive skin. Rosacea responds to azelaic acid, ivermectin, metronidazole or a low-dose tetracycline course of 6 to 16 weeks.

Which triggers should I avoid?

The common list is alcohol, spicy food, hot drinks, sunlight, heat, cold, hard exercise and stress, but few people react to all of them. Keep a daily diary for at least 2 weeks, better 4 to 6, and wear SPF 30 every day; sun is the one trigger almost everyone shares.

Sources

• NHS: Rosacea · symptoms, common triggers, antibiotics for 6 to 16 weeks, SPF 30 every day, eye warning signs; page reviewed March 2023
• American Academy of Dermatology: Lasers and lights, how well they treat rosacea · 50 to 75% fewer vessels after 1 to 3 treatments, about 20% less redness, sessions 3 to 4 weeks apart, results 3 to 5 years, side effects, board-certified dermatologist
• Schaller M et al., Recommendations for rosacea diagnosis, classification and management: update from the global ROSacea COnsensus 2019 panel, Br J Dermatol 2020 (PMC) · phenotype features, diagnostic and major criteria, vascular lasers and IPL for persistent erythema, clear rather than almost clear, 19 dermatologists and 2 ophthalmologists
• van Zuuren EJ et al., Interventions for rosacea based on the phenotype approach: an updated systematic review including GRADE assessments, Br J Dermatol 2019 (PMC) · 152 studies, 20,944 participants; low to moderate certainty for PDL, Nd:YAG and IPL on telangiectasia; azelaic acid, ivermectin, metronidazole, brimonidine, doxycycline and isotretinoin figures

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This guide is for general information. It does not replace medical or professional cosmetic advice or an examination.