Dear Paula,

I enjoy your books as well as your products. I need help sorting out conflicting advice from two dermatologists. First, a little history: I am 48 and have rosacea. My regular dermatologist encouraged me to see a cosmetic dermatologist for laser treatments for redness on my cheeks and nose and for various spider veins.

The cosmetic derm said I needed to stop using Retin-A for a month prior to laser treatment. I have had several treatments and have stopped using Retin-A. The cosmetic derm doesn't recommend using Retin-A after I am done with my series of treatments. He feels it causes and contributes to spider veins. When I mentioned this to my original derm, she dismissed it and told me that she uses retinoids and feels they are very beneficial. She also has rosacea. She feels she offers her patients the best available treatments and that I can and should use Retin-A when I am done with my laser treatments. So who is right?

I respect both doctors but I don't want to undo the benefits from the laser treatments (which I spent a lot of money on). Here's the thing: my pores seemed much smaller and my skin was smoother when I used Retin-A (although it would cause my skin to be flaky, which is why the cosmetic derm told me it wasn't right for me. He said the flakiness was an indication of inflammation. I thought it was a typical response of using retinoids.

I am currently using Finacea (instead of Retin-A) in the evening and taking Oracea (doxycycline, an oral antibiotic) in the morning and using Klaron in the morning. Can you help me figure out what is best? Are there any studies that support the notion that retinoids cause spider veins? I am so confused and would be grateful for your help.

Michelle, via email

Dear Michelle,

It is certainly understandable why you would be confused! It's frustrating when you get conflicting advice from medical professionals you trust, but that's why two opinions can be useful, the conflicting advice can be help you weigh the pros and cons of each.

You didn't specify the type of laser treatments you've been having, but whether it was an actual laser or a series of Intense Pulsed Light (IPL) treatments, the advice concerning not using Retin-A prior to your treatments is standard. The belief is that discontinuing use of topical retinoids will make skin less sensitive to the laser or light-emitting device being used to correct redness and broken capillaries (technically known as telangiectasias). In most cases, you can resume use of a retinoid once the series of treatments is done.

Some dermatologists advise their patients to use the retinoid in between treatments, waiting a few days after each procedure to begin again, then stopping use a week or so before the next treatment. There are no hard and fast rules here, so you need to consider your derm's advice as well as how your skin is doing.

As for your question about whether or not topical retinoids cause broken capillaries, from the research I've seen that is not a side effect to be concerned with. What the research shows is that topical retinoids can actually help reduce broken capillaries, especially those caused by sun damage, and they're also potentially helpful for rosacea. (Sources: Clinical Interventions in Aging, March 2008, pages 71-76; Skin Pharmacology and Applied Skin Physiology, September-October 2001, pages 303-315; and Archives of Dermatology, May 1991, pages 659-665).

Of course, not everyone can tolerate topical retinoids whether they have rosacea or not. Because rosacea tends to make skin more sensitive, the common, often transient side effects of topical retinoid usage (flaking, redness, and stinging) may in fact be more pronounced and persistent. Does that mean someone with rosacea should avoid retinoids? Not necessarily. If undesirable side effects such as flaking persist, you don't have to stop using it, but you should decrease how often you apply it. Every other day can still net positive results from using Retin-A.

While I can't provide medical advice, my feeling is that your original dermatologist recommendation to continue using Retin-A makes sense. You can also consider asking this dermatologist about other forms of retinoids or a lower strength of Retin-A.

One more point to consider: the flaking from Retin-A may have been exacerbated by other skin care products you're using that contain fragrance, fragrant plant extracts, or irritating ingredients. You could also be having problems from other prescription topical products you've been using to manage symptoms of rosacea. For example, Klaron contains 10% of a form of sulfur that has antibacterial action but is known to cause stinging, irritation, and a burning sensation. I suspect you don't need this plus the Oracea and Finacea to control symptoms of rosacea but that is something to discuss with your physician. From many viewpoint this combination can be overkill and adding a topical retinoid to the mix (never mind regular skin-care products like sunscreen and exfoliants) will assuredly send your skin into sensitivity overdrive. If it were me, I'd speak to my dermatologist about stopping the Klaron and alternating nightly application of a topical retinoid (perhaps Renova) with the Finacea. And be sure you're protecting your skin daily with a gentle, mineral-based sunscreen (or foundation with sunscreen) rated SPF 15 or greater. Paula's Choice Barely There Sheer Matte Tint SPF 20 would be an excellent option for you.