Beyond Lifting: Superficial-Targeted Monopolar Radiofrequency for Erythematotelangiectatic Rosacea

Abstract

Noninvasive monopolar radiofrequency (NMRF) is an established modality for skin tightening, but its role in inflammatory dermatoses such as rosacea remains poorly defined. We report a man in his forties with an erythematotelangiectatic rosacea (ETR) phenotype, characterized by persistent centrofacial erythema, flushing, and xerosis, who underwent two sessions of multifrequency NMRF (XERF; Cynosure Lutronic, Goyang, Korea) at 4-week intervals using an off-label, superficial-targeted protocol (shallow setting, intensity level 5; 6.78 MHz; approximately 250 pulses; approximately 23,000 J cumulative energy per session; fragmented-pulse mode with controlled off-time). One month after the second session, facial erythema was visibly reduced and skin tone appeared more uniform. Antera 3D (Miravex, Dublin, Ireland) multispectral imaging showed a 24.3% decrease in average hemoglobin level (2.016 to 1.525) and a 36.9% decrease in hemoglobin variation (0.255 to 0.161). Surface scaling and xerosis also improved clinically. This single case suggests that superficial-targeted NMRF may reduce erythema and improve barrier-related symptoms in ETR through combined vascular, anti-inflammatory, and epidermal barrier mechanisms, beyond its established tissue-tightening effect, although these findings are exploratory and controlled studies incorporating standardized imaging, transepidermal water loss, histology, and inflammatory mediator assessment are needed to test this hypothesis.

Introduction

Noninvasive monopolar radiofrequency (NMRF) is an established technology for skin tightening. Its effects are attributed primarily to controlled volumetric heating of the dermis and subcutaneous fibrous septa, resulting in immediate collagen contraction followed by delayed dermal remodeling.¹ Because radiofrequency current heats tissue resistively in proportion to local impedance, and impedance is frequency-dependent, the depth of maximal heating varies with the operating frequency: higher frequencies, as used in this superficial-targeted protocol, concentrate energy deposition closer to the epidermal–dermal junction, whereas the lower frequencies typical of deep-lifting or fractional/microneedle RF platforms extend heating to greater depth.^1,2 Its role in inflammatory dermatoses such as rosacea, however, remains poorly defined; radiofrequency-based devices have been reported to modulate inflammatory and fibrotic processes in other conditions such as hypertrophic scarring,³ but energy-based treatment of rosacea-associated erythema has relied mainly on vascular-selective lasers, intense pulsed light, and fractional or microneedle radiofrequency rather than on noninvasive monopolar bulk heating.^4–6 An early report suggested that subthermal 448-kHz monopolar radiofrequency could reduce post-laser erythema in patients with erythematotelangiectatic rosacea (ETR),⁷ but the use of NMRF as a rosacea-directed intervention has rarely been described. We report a patient with an ETR phenotype who improved after an off-label NMRF protocol designed to favor relatively superficial dermal heating. This observation raises the possibility that, beyond tissue tightening, NMRF may have vascular- and barrier-directed effects.

Case Presentation

A man in his forties presented with persistent centrofacial erythema, flushing, and xerosis consistent with ETR, a phenotype dominated by neurovascular dysregulation and impaired epidermal barrier function.⁸ He underwent two sessions of multifrequency NMRF (XERF; Cynosure Lutronic, Goyang, Korea) at 4-week intervals. Treatment was performed using the shallow setting (intensity level 5; 6.78 MHz), with approximately 250 pulses and a cumulative energy of approximately 23,000 J per session. A fragmented-pulse mode with controlled off-time was selected to limit thermal accumulation. Consistent with the frequency-dependent heating principle described above, the 6.78-MHz shallow configuration was selected to bias energy deposition toward relatively superficial dermal compartments while minimizing deep adipose heating, in line with finite-element and histologic analyses of this platform.¹ These parameters do not represent a manufacturer-validated or standardized rosacea protocol; they were selected empirically by the author based on general device operating principles for superficial-targeted heating.

Outcomes were assessed clinically and with Antera 3D (Miravex, Dublin, Ireland), a multispectral imaging system used to quantify hemoglobin-related chromophores and erythema.⁹ One month after the second session, persistent facial erythema was visibly reduced and skin tone appeared more uniform (Figure 1A and B). The average hemoglobin level decreased from 2.016 to 1.525 (−24.3%), and hemoglobin variation decreased from 0.255 to 0.161 (−36.9%) (Figure 1C). Surface scaling and xerosis also improved clinically, although transepidermal water loss, stratum corneum hydration, and histologic endpoints were not measured.

Figure 1.

Clinical and instrumental improvement of erythematotelangiectatic rosacea after monopolar radiofrequency treatment. (A) Representative clinical photographs at baseline (left) and 1 month after two treatment sessions (right), showing reduced facial erythema. (B) Magnified periorbital images demonstrating decreased vascular prominence and diffuse erythema. (C) Antera 3D hemoglobin analysis showing reductions in the average hemoglobin level (2.016 to 1.525) and hemoglobin variation (0.255 to 0.161).

Discussion

Rosacea pathophysiology integrates neurovascular dysregulation, innate immune activation involving the cathelicidin/LL-37 axis, and barrier impairment reflected by increased transepidermal water loss.⁸ In the present case, the reduction in the Antera 3D hemoglobin signal suggests a decrease in superficial vascular congestion; however, a single uncontrolled observation cannot distinguish vasomotor modulation from structural microvascular change. Antera 3D hemoglobin mapping is itself a colorimetric surrogate for cutaneous blood content,⁹ and it cannot independently differentiate transient vasodilation from more sustained structural microvascular remodeling, which further constrains mechanistic interpretation of the observed signal change. Fractional and microneedle radiofrequency studies in rosacea and LL-37-induced rosacea-like dermatitis have reported improvement in erythema and inflammatory activity, including suppression of NF-κB signaling, supporting a plausible anti-inflammatory and vascular rationale.^5,6 These findings should not be directly extrapolated to noninvasive monopolar radiofrequency, but they provide a biologic framework for further study.

In the specific context of ETR, superficial-targeted NMRF and intense pulsed light (IPL) act through different primary mechanisms. IPL targets oxyhemoglobin as a chromophore, producing photothermal coagulation of superficial dermal vessels, and is among the most established vascular-selective options for facial erythema and telangiectasia in rosacea,¹⁰ although its effect is largely confined to the vasculature and it carries a risk of dyspigmentation in darker skin types. Superficial-targeted NMRF, in contrast, delivers non-chromophore-dependent volumetric resistive heating across the papillary and superficial reticular dermis; it is not limited by melanin competition and may concurrently affect the dermal–epidermal junction and epidermal barrier, but its vascular effect is presumably less selective and more indirect than photothermal vessel coagulation. These differences suggest that NMRF and IPL may prove complementary rather than interchangeable in ETR, a hypothesis that would require direct, controlled comparison to confirm.

The concurrent improvement in xerosis and scaling suggests a possible barrier-related component. Controlled subablative dermal heating can induce heat-shock responses, including HSP47, that are associated with collagen synthesis,¹¹ and radiofrequency has been reported to attenuate age-related changes in the dermal–epidermal junction by upregulating basement-membrane components such as collagen XVII and laminins in animal skin.¹² Strengthening of the dermal matrix and dermal–epidermal junction could theoretically improve epidermal resilience against rosacea triggers. In this case, however, the absence of transepidermal water loss, corneometry, biopsy, or inflammatory mediator data precludes mechanistic confirmation, and this pilot observation should be interpreted accordingly.

Conclusion

This single pilot case suggests that superficial-targeted NMRF may reduce erythema and improve surface dryness in an ETR phenotype. The effect is unlikely to be purely structural and may involve combined modulation of superficial vascular tone, inflammation, and epidermal barrier stability. These observations remain exploratory and should not be interpreted as evidence of therapeutic efficacy. Controlled, split-face or head-to-head studies—ideally benchmarked against established vascular-selective modalities such as IPL—incorporating standardized photography, hemoglobin or erythema imaging, transepidermal water loss, stratum corneum hydration and lipid composition, epidermal tight-junction and barrier-protein expression, histology, and inflammatory mediators such as LL-37 are warranted before any therapeutic claim can be made.

Funding Statement

Cynosure Lutronic Inc. provided the study device. No additional external financial support was received.

Data Sharing Statement

The datasets (clinical photographs and Antera 3D imaging data) generated and analyzed during this case are not publicly available due to patient confidentiality but are available from the corresponding author on reasonable request.

Ethics Statement

The study complied with the Declaration of Helsinki and ICH-GCP guidelines and was approved by the Institutional Review Board of Kangbuk Samsung Hospital (IRB No. KBSMC 2025-06-007-004). This institutional approval, together with the patient’s written informed consent described below, covers the publication of the case details, clinical photographs, and imaging data presented in this report.

Consent for Publication

Written informed consent was obtained from the patient for treatment and for publication of this case report and any accompanying clinical images. The patient has been shown the contents of the manuscript to be published.

Author Contributions

Won-Serk Kim made a significant contribution to the work reported, whether in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising, and critically reviewing the article; gave final approval of the version to be published; has agreed on the journal to which the article was submitted; and agrees to be accountable for all aspects of the work.

Disclosure

Won-Serk Kim has served as a consultant for Cynosure Lutronic Inc., which also provided the study device used in this report. The sponsor had no role in the design of this report, the analysis or interpretation of the clinical and imaging data, or the decision to submit the manuscript for publication. The treatment parameters described (shallow setting, fragmented-pulse mode) are not a manufacturer-validated or standardized rosacea protocol; they were selected empirically by the author, and the findings should be regarded as a pilot, hypothesis-generating observation rather than a validated treatment recommendation. The authors report no other conflicts of interest in this work.