The Evolution of Melasma Therapy: Targeting Melanosomes Using Low-Fluence Q-Switched Neodymium-Doped Yttrium Aluminium Garnet Lasers

Use of Picosecond Laser for Melasma Treatment: A Narrative Review

Background: Melasma results from the imbalance of the mechanisms that regulate skin pigmentation, causing the appearance of hyperpigmented patches. Treatment includes topical and oral agents, chemical peelings, microneedling, and laser therapy. The picosecond laser was developed to minimize pain and skin discoloration, which can sometimes be associated with laser treatments. It emits short pulses of energy that last from 300 to 500 picoseconds, leading to a more significant fragmentation of melanin, with miniminal risk of scarring and thermal lesions in the surrounding skin. Objective: The authors aimed to review the use of picosecond laser in the treatment of melasma and further provide an overview of the other current available options. Conclusions: While the use of picosecond laser for the treatment of melasma has yielded good results, further studies with longer follow-up periods and a higher number of patients are needed.

The Low-Fluence Q-Switched Nd:YAG Laser Treatment for Melasma: A Systematic Review

Melasma is a common pigmentary disorder with a complex pathogenesis, of which the treatment is challenging. Conventional treatment often leads to inconsistent results with unexpected pigmentary side effects and high recurrence rates. Recently, the low-fluence Q-switched Nd:YAG laser (LFQSNY) has been widely used for treating melasma, especially in Asia. We reviewed literatures on the LFQSNY treatment of melasma published between 2009 and May 2022 to evaluate the efficacy and adverse events, including its combination therapy. A systematic PubMed search was conducted and a total of 42 articles were included in this study. It was hard to summarize the heterogenous studies, but LFQSNY appeared to be a generally effective and safe treatment for melasma considering the results of previous conventional therapies. However, mottled hypopigmentation has been occasionally reported to develop and persist as an adverse event of LFQSNY, which may be associated with the high accumulated laser energy. When used aggressively, even LFQSNY can induce hyperpigmentation via unwanted inflammation, especially in darker skin. Although few studies have reported considerable recurrence rates three months after treatment, unfortunately, there is a lack of the long-term follow-up results of LFQSNY in melasma. To enhance the effectiveness and reduce the adverse events, LFQSNY has been used in combination with other treatment modalities in melasma, including topical bleaching agents, oral tranexamic acid, chemical peeling, or diverse energy-based devices, which generally reduced side effects with or without significant superior efficacy compared to LFQSNY alone.

Postinflammatory and rebound hyperpigmentation as a complication after treatment efficacy of telangiectatic melasma with 585 nanometers Q-switched Nd: YAG laser and 4% hydroquinone cream in skin phototypes III-V

BACKGROUND

The potential efficacy of vascular component-targeted laser has been evaluated for the treatment of melasma, which commonly found with the co-existence of telangiectasia.

AIMS

To evaluate the treatment efficacy and safety of 585-nm QSNYL and 4% HQ cream combination vs 4% HQ cream alone for telangiectatic melasma in the skin phototypes III-V.

PATIENTS/METHODS

Twenty-one Thai female patients with telangiectatic melasma and Fitzpatrick skin phototypes (FPTs) III-V were randomly treated with the 585-nm QSNYL on one side of the face for five sessions at 2-week intervals. All patients were assigned to apply HQ cream daily at night on both sides of the face for 10 weeks and a broad-spectrum sunscreen regularly throughout the study. The treatment efficacy and safety were evaluated using the Modified Melasma Area and Severity Index (mMASI), biometric evaluation, patient assessment, and adverse effects.

RESULTS

The combination-treated side yielded more significant improvement of mMASI than the topical-treated side at weeks 2, 4, and 8, respectively. However, 19% of the patients developed postinflammatory hyperpigmentation (PIH) on the laser-treated side, especially in FPTs IV-V and rebound hyperpigmentation. There was a significant improvement of hemoglobin and melanin index, but without statistical difference between the two treatment groups.

CONCLUSIONS

The combination of 585-nm QSNYL and HQ treatment yields treatment efficacy and skin rejuvenation effects for telangiectatic melasma. Nonetheless, a high incidence of PIH and rebound hyperpigmentation is adversely developed in dark FPT. Thus, this laser treatment should be cautiously applied in those with dark FPTs IV-V to avoid laser-induced pigment alteration.

Melasma: an Up-to-Date Comprehensive Review

Melasma is a common acquired condition of symmetric hyperpigmentation, typically occurring on the face, with higher prevalence in females and darker skin types. Multiple etiologies, including light exposure, hormonal influences, and family history, have been implicated in the pathogenesis of this disorder. Overall prevalence ranges widely at 1-50%, since values are typically calculated within a specific ethnic population within a geographic region. Histologically, melasma can display increased epidermal and/or dermal pigmentation, enlarged melanocytes, increased melanosomes, solar elastosis, dermal blood vessels, and, occasionally, perivascular lymphohistiocytic infiltrates. Various topical, oral, and procedural therapies have been successfully used to treat melasma. Traditional topical therapies including hydroquinone, tretinoin, corticosteroids, and triple combination creams; however, other synthetic and natural topical compounds have also shown varying efficacies. Promising oral therapies for melasma include tranexamic acid, Polypodium leucotomos, and glutathione. Procedures, including chemical peels, microneedling, radiofrequency, and lasers, are also often used as primary or adjunctive treatments for melasma. Notably, combination therapies within or across treatment modalities generally result in better efficacies than monotherapies. This review serves as a comprehensive update on the current understanding of the epidemiology, pathogenesis, clinical and histologic features of melasma, as well as treatments for this common, yet therapeutically challenging, condition.

Retreatment using a dual mode of low-fluence Q-switched and long-pulse Nd:YAG laser in patients with melasma aggravation after previous therapy

BACKGROUND

Aggravated melasma after treatment is vulnerable to stimulation, can easily deteriorate, and may be distressing without proper management.

OBJECTIVE

To retrospectively assess the effectiveness and safety of combination therapy using low-fluence Q-switched neodymium-doped yttrium aluminum garnet (Nd:YAG) laser (QSNY) and long-pulse Nd:YAG laser (LPNY) (dual toning) in patients with rebound melasma.

MATERIALS AND METHODS

A total of 30 patients with aggravated melasma after previous therapy who were treated with dual toning were enrolled. A total of 10 sessions were conducted at 1-week intervals, followed by maintenance treatment. The results were evaluated using the modified Melasma Area and Severity Index (mMASI) and the physician's global assessment (PGA) before and 2 months after completing the 10 treatment sessions.

RESULTS

The baseline mMASI was 10.48 ± 3.64, which significantly decreased to 3.22 ± 1.45 2 months after completing the 10 treatment sessions (p < 0.001). Twenty-four patients (80%) had PGA grade 4 (76-100% improvement) and 6 patients (20%) had PGA grade 3 (51-75% improvement).

CONCLUSION

Dual toning may be a safe and effective salvage treatment for patients with aggravated melasma after previous treatment. LPNY may stabilize melasma activity to prevent rebound hyperpigmentation via dermal remodeling.