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Beyzaee AM, Goldust M, Rokni GR, Patil A, Mostaghiman R, Golpour M. Comparative effectiveness and safety of topical methimazole 5% monotherapy versus combination of Q-Switched Nd: YAG Laser and topical methimazole 5% in patients with refractory melasma. J Cosmet Dermatol 2023; 22:1774-1779. [PMID: 36847668 DOI: 10.1111/jocd.15641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 12/10/2022] [Accepted: 01/05/2023] [Indexed: 03/01/2023]
Abstract
INTRODUCTION Melasma is an acquired pigmentary disorder which currently has no definitive treatment. Although topical drugs containing hydroquinone are the basis of treatments, they are usually associated with recurrence. We aimed to evaluate the effectiveness and safety of monotherapy with topical methimazole 5% versus combination of Q-Switched Nd: YAG Laser and topical methimazole 5% in patients with refractory melasma. METHODS A total of 27 women with refractory melasma were included. We applied topical methimazole 5% (once a day) with three passes of QSNd: YAG laser (Wavelength: 1064 nm, pulse energy: 750 mJ, fluence: 1.50 J/cm2 , spot size: 4 × 4 mm, hand piece: fractional, JEISYS company) for six sessions on the right half of the face, and topical methimazole 5% (once a day) on the left half of the face, for each patient. The treatment course was 12 weeks. Evaluation of effectiveness was done with the Physician Global Assessment (PGA), Patient Global Assessment (PtGA), Physician satisfaction (PS), Patients satisfaction (PtS), and mMASI score. RESULTS PGA, PtGA, and PtS were not significantly different between the two groups at any time (p > 0.05). PS in the laser plus methimazole group was significantly better than methimazole group at 4th, 8th, and 12th weeks (p < 0.05). The rate of PGA improvement in the combination group was significantly better than the monotherapy over time (p < 0.001). The changes of mMASI score between the two groups did not significantly differ at any time (p > 0.05). There was no significant difference in the adverse events between the two groups. CONCLUSION Combination therapy with topical methimazole 5% and QSNY laser can be considered as an effective way to treat refractory melasma.
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Affiliation(s)
| | - Mohamad Goldust
- Department of Dermatology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Ghasem Rahmatpour Rokni
- Department of Dermatology, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Anant Patil
- Department of Pharmacology, Dr. DY Patil Medical College, Navi Mumbai, India
| | - Reza Mostaghiman
- Department of Dermatology, Mazandaran University of Medical Sciences, Sari, Iran
| | - Masoud Golpour
- Department of Dermatology, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
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Fractional Q-Switched 1064 nm Laser for Treatment of Atrophic Scars in Asian Skin. Medicina (B Aires) 2022; 58:medicina58091190. [PMID: 36143867 PMCID: PMC9505728 DOI: 10.3390/medicina58091190] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 08/26/2022] [Accepted: 08/26/2022] [Indexed: 11/18/2022] Open
Abstract
Background and Objectives: Asian patients with Fitzpatrick skin type III–IV are a less studied subtype of patients in the medical literature. Q-Switched, 1064 nm neodymium-doped yttrium aluminum garnet (Nd: YAG) laser with a fractionated beam profile (QSF) is a new modality that was reported to be effective in the treatment of scars. This study aims to evaluate the efficacy and safety of QSF Nd: YAG laser in treating scars in Asian patients. Materials and Methods: A total of 29 Subjects were treated with 1064 nm QSF laser. Each patients had three treatments with a fractionated microlens array handpiece every 8 weeks). Efficacy of treatment was evaluated using the Goodman and Baron’s quantitative grading scale before and 3 months after the last treatment. Results: All 29 patients treated had significant improvement of acne scars according to Goodman and Baron’s Quantitative Global Acne Scarring Grading System. No side effect has been observed except some minor erythematous reactions in three patients. Conclusions: Our results confirm that the 1064 nm QSF Nd: YAG laser is a safe and effective technique for treating scars in Asians.
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Mahajan VK, Patil A, Blicharz L, Kassir M, Konnikov N, Gold MH, Goldman MP, Galadari H, Goldust M. Medical therapies for Melasma. J Cosmet Dermatol 2022; 21:3707-3728. [PMID: 35854432 DOI: 10.1111/jocd.15242] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 07/11/2022] [Indexed: 01/19/2023]
Abstract
Melasma is a common malady affecting all races with a higher incidence in Hispanics, Middle Eastern, Asians and African origin females (Fitzpatrick skin phototypes III-V). Women are affected much more often than men. Melasma remains a significant cause of cosmetic morbidity and psychosocial embarrassment affecting quality of life necessitating effective and reliable treatment. Unfortunately, treatment remains unsatisfactory due to limited efficacy, adverse effects and relapses after stopping treatment. Although chemical peels, laser and light therapies and dermabrasion may have utility, the evidence available for their efficacy is limited and they often cause post inflammatory hyperpigmentation particularly in individuals with darker skin types. Medical therapies remain mainstay in the management of melasma. The triple combination, hydroquinone 4%, tretinoin 0.05% and fluocinolone acetonide 0.01% (Triluma, Galderma, Ft. Worth Texas, often modified incorporating different corticosteroids) remains the only US FDA approved treatment for melasma and is the gold standard due its demonstrated efficacy across ethnicities. Oral tranexamic acid alone or in combination with other modalities has also shown significant efficacy. Several cosmeceuticals and botanical extracts used as skin lightening agents have been demonstrated to be useful. Physical sunscreens containing zinc oxide, iron oxide, titanium dioxide, and silicones provide photoprotective and camouflage effect. We propose that a multimodality approach to the treatment of melasma is the most effective treatment approach. This review is focused on the medical therapies for melasma.
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Affiliation(s)
- Vikram K Mahajan
- Department of Dermatology, Venereology & Leprosy Dr. Rajendra Prasad Government Medical College Kangra, Tanda, India
| | - Anant Patil
- Department of Pharmacology, Dr. DY Patil Medical College, Navi Mumbai, India
| | - Leszek Blicharz
- Department of Dermatology, Medical University of Warsaw, Warsaw, Poland
| | - Martin Kassir
- Founding director, Worldwide laser institute, Dallas, USA
| | | | - Michael H Gold
- Gold Skin Care Center, Tennessee Clinical Research Center, Nashville, TN, USA
| | - Mitchel P Goldman
- Cosmetic Laser Dermatology: A West Dermatology Company, San Diego, CA, USA.,Department of Dermatology, University of California, San Diego, CA, USA
| | - Hassan Galadari
- College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Mohamad Goldust
- Department of Dermatology, University Medical Center Mainz, Mainz, Germany
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Q-Switched Laser Combined with Intense Pulsed Laser in the Treatment of Melasma Based on Reflection Confocal Microscope. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:4413130. [PMID: 35813427 PMCID: PMC9270135 DOI: 10.1155/2022/4413130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 05/03/2022] [Accepted: 05/07/2022] [Indexed: 11/22/2022]
Abstract
Chloasma is a prevalent clinical hyperpigmentation skin disorder that causes symmetrical brown to tan patches on the cheeks, as well as the neck and forearms on rare occasions. The pathophysiology of this condition is complicated, and there is now no cure. Under the light microscope, the full-thickness melanin of the epidermis in the skin lesions was increased, and the dermal chromophages increased. At present, the treatment of melasma mainly includes topical drugs, chemical peels, systemic drugs, laser therapy, and traditional Chinese medicine. With the development of medical technology, intense pulsed light and Q-switched laser have been widely used in the treatment of melasma, which can emit laser beams to penetrate the dermis uniformly to treat deep pigmented lesions in the dermis. After a stable treatment outcome for melasma is achieved, it is important to minimize side effects such as postinflammatory hyperpigmentation and skin irritation. Therefore, this paper uses a reflection confocal microscope to establish an evaluation index system and then uses a neural network to evaluate the treatment effect. The work of this paper is as follows: (1) this paper introduces various methods of treating melasma at home and abroad and focuses on the application of intense pulsed light therapy and low-energy Q-switched Nd: YAG laser in the treatment of melasma. (2) In this paper, the case data samples are trained with the designed BP network to obtain a reliable evaluation network model. (3) The results and mistakes of the evaluation are produced by training the genetic algorithm optimized backpropagation (GA-BP) network structure model to evaluate the treatment effect of chloasma. Finally, it has been demonstrated that the GA-BP network has great accuracy and stability.
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Abstract
Melasma is a chronic and relapsing skin condition. Although melasma is usually asymptomatic, it can be associated with immense psychosocial stress and greatly impact a patient's quality of life. Over the years, many different treatments have been used, ranging from daily photoprotection, topical lightening creams, and oral agents to laser and light-based therapies; however, efficacy is often limited with such treatments, and there is currently no effective modality to prevent recurrence. Although treatment strategies had originally centered on the use of hydroquinone, newer modalities now include oral tranexamic acid and lasers. We examined previous and ongoing debates related to melasma treatments and have reviewed the current efficacy and safety of available treatments. Critical components essential to the successful management of melasma are the setting of patient expectations and assurance of treatment compliance.
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Affiliation(s)
- Kanika Kamal
- Harvard Medical School, Harvard University, Boston, Massachusetts, USA.
| | - Kerry Heitmiller
- Department of Dermatology and Cutaneous Biology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Liu Y, Wu S, Wu H, Liang X, Guo D, Zhuo F. Comparison of the Efficacy of Melasma Treatments: A Network Meta-Analysis of Randomized Controlled Trials. Front Med (Lausanne) 2021; 8:713554. [PMID: 34660626 PMCID: PMC8511390 DOI: 10.3389/fmed.2021.713554] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 08/20/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Melasma is an acquired pigmentation disorder with challenges in treatment because of its refractory nature and high risk of recurrence. Objectives: This study aimed to compare the efficacy and side effects of 14 common therapies for melasma using a systematic review and network meta-analysis (NMA). Methods: The PubMed, Embase, and Cochrane Library databases were searched till December 2020 using the melasma area and severity index as a therapeutic index. A total of 59 randomized controlled trials (RCTs) met the inclusion criteria and were selected. Results: The ranking of relative efficacy compared with placebo in descending order was Q-switched Nd:Yag 1,064-nm laser (QSND), intense pulsed light, ablative fractional laser (AFL), triple combined cream (TCC), topical vitamin C, oral tranexamic acid (oTA), peeling, azelaic acid, microneedles (MNs), topical tranexamic acid (tTA), tretinoin, picosecond laser, hydroquinone (HQ), and non-AFL. Moreover, QSND was more effective than HQ and tTA against melasma. The ranking of percentage (%) of side effects in ascending order for each of 14 therapies with more than 80 participants was tretinoin (10.1%), oTA (17.6%), HQ (18.2%), AFL (20.0%), QSND (21.5%), TCC (25.7%), tTA (36.75%), peeling (38.0%), and MN (52.3%). Taking both efficacy and safety into consideration, TCC was found to be the most favorable selection among the topical drugs for melasma. QSND and AFL were still the best ways to treat melasma among photoelectric devices. oTA as system administration was a promising way recommended for melasma. Among 31 studies, 87% (27/31) studies showed that the efficacy of combination therapies is superior to that of single therapy. The quality of evidence in this study was generally high because of nearly 50% of split-face RCTs. Conclusions: Based on the published studies, this NMA indicated that QSND, AFL, TCC, and oTA would be the preferred ways to treat melasma for dermatologists. However, more attention should be paid to the efficacy and safety simultaneously during the clinical application. Most of the results were in line with those of the previous studies, but a large number of RCTs should be included for validation or update. Systematic Review Registration: identifier: CRD42021239203.
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Affiliation(s)
- Yi Liu
- Department of Dermatology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Shanshan Wu
- National Clinical Research Center of Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Haixuan Wu
- Department of Dermatology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Xuelei Liang
- Department of Dermatology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Dechao Guo
- Department of General Surgery, The Third Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Fenglin Zhuo
- Department of Dermatology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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Al-Dhalimi MA, Yasser RH. Evaluation of the of the efficacy of Fractional Erbium-Doped Yttrium Aluminum Garnet Laser-Assisted Drug Delivery of Kojic Acid in the Treatment of Melasma; A split face, comparative clinical study. J COSMET LASER THER 2021; 23:65-71. [PMID: 34407729 DOI: 10.1080/14764172.2021.1964536] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Melasma is a common, difficult to treat hyperpigmentary disorder. Recently, ablative fractional lasers were utilized to enhance topical agents delivery to treat different skin conditions. This work was designed to evaluate the efficacy of fractional Er:YAG laser in enhancing the effect of topical kojic acid in patients with facial melasma. The patients were randomly treated in a split-face mode, by simple randomization, either with kojic acid alone on one side or combined with fractional Er:YAG laser on the other side. Twenty five patients completed six laser sessions at 2 week interval. The severity of melasma was assessed before and after treatment in addition to 3 months follow up after the last treatment session. The response to the treatment was evaluated by Melasma Area and Severity Index Score, physician global assessment of photographs and patient satisfaction. The side treated with fractional Er:YAG laser and kojic acid cream was found to have a statistically significant better improvement than the side treated with kojic acid alone. The patients were reported mild tingling sensation and mild erythema on both sides. Using combination of fractional Er:YAG laser and topical kojic acid was effective in the treatment of melasma.
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Affiliation(s)
- Muhsin A Al-Dhalimi
- Department of Dermatology, Faculty of Medicine, University of Kufa, Najaf, Iraq
| | - Raya Hamid Yasser
- Department of Dermatology, Alsader Teaching Hospital, AlDiwanya Health Directorate, Iraq
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Nautiyal A, Wairkar S. Management of hyperpigmentation: Current treatments and emerging therapies. Pigment Cell Melanoma Res 2021; 34:1000-1014. [PMID: 33998768 DOI: 10.1111/pcmr.12986] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 04/16/2021] [Accepted: 05/10/2021] [Indexed: 11/30/2022]
Abstract
Hyperpigmentation of the skin refers to a dermatological condition which alters the color of the skin, making it discolored or darkened. The treatments for hyperpigmentation disorders often take very long to show results and have poor patient compliance. The first-line treatment for hyperpigmentation involves topical formulations of conventional agents such as hydroquinone, kojic acid, and glycolic acid followed by oral formulations of therapeutic agents such as tranexamic acid, melatonin, and cysteamine hydrochloride. The second-line approaches include chemical peels and laser therapy given under the observation of expert professionals. However, these therapies pose certain limitations and adverse effects such as erythema, skin peeling, and drying and require long treatment duration to show visible effects. These shortcomings of the conventional treatments provided scope for further research on newer alternatives for managing hyperpigmentation. Some of these therapies include novel formulations such as solid lipid nanocarriers, liposomes, phytochemicals, platelet-rich plasma, microneedling. This review focuses on elaborating on several hyperpigmentation disorders and their mechanisms, the current, novel and emerging treatment options for management of hyperpigmentation.
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Affiliation(s)
- Avni Nautiyal
- Shobhaben Pratapbhai Patel School of Pharmacy & Technology Management, SVKMs NMIMS, Mumbai, India
| | - Sarika Wairkar
- Shobhaben Pratapbhai Patel School of Pharmacy & Technology Management, SVKMs NMIMS, Mumbai, India
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Comparative Efficacy of Fractional CO2 Laser and Q-Switched Nd:YAG Laser in Combination Therapy with Tranexamic Acid in Refractory Melasma: Results of a Prospective Clinical Trial. COSMETICS 2021. [DOI: 10.3390/cosmetics8020037] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Melasma manifests as hyperpigmented macules and patches, usually affecting the face, neck, and rarely upper limbs. This study evaluated comparative efficacy of a fractional CO2 laser with a Q-Switched Nd:YAG laser in combination therapy with tranexamic acid in refractory melasma. A total of 30 patients with refractory melasma were included in this study. The fractional CO2 laser (power: 30 w, pulse energy: 30 mJ, tip type: 300, pulse rate: 100/cm2) was used on one side of the patients’ face and three passes of the Q-Switched Nd:YAG (QSNY) laser (Wavelength: 1064 nm, pulse energy: 750 mJ, fluence: 1.50 J/cm2, spot size: 4 mm × 4 mm, hand piece: fractional) were used on the opposite side of the same patient’s face for six sessions. During the course of laser therapy, all patients received oral tranexamic acid 250 mg twice daily. Melasma area and severity index (MASI) score and physician’s satisfaction and patient’s satisfaction were analyzed. Thirty patients (mean age 39.97) were included. Patient global assessment (PtGA) in the fractional CO2 laser group was significantly better than the Q-Switched Nd:YAG laser group at 4th, 8th and 12th weeks (p-value < 0.001). According to PtGA, the improvement was significant in both groups over time. Physician global assessment (PGA) at the 8th and 12th weeks, and physician satisfaction (PS) at the 8th week, in the fractional CO2 laser group was significantly better than the Q-Switched Nd:YAG laser group (p-value < 0.05). The PGA in both groups significantly reduced over time. The MASI score significantly decreased in both groups over time. The MASI score in the fractional CO2 laser group decreased more than the Q-Switched Nd:YAG laser group over time (p < 0.001). The most common side effects reported were erythema and discomfort, which subsided in less than 24 h. A fractional CO2 laser with oral tranexamic acid is an effective and well tolerated therapeutic method for the treatment of patients with refractory melasma.
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Evaluation of Efficacy and Safety Profile of Intense Pulsed Light Treatment in Melasma in Darker Skin Type. SERBIAN JOURNAL OF DERMATOLOGY AND VENEREOLOGY 2020. [DOI: 10.2478/sjdv-2020-0001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Introduction. We undertook a prospective, interventional study to evaluate the efficacy and safety profile of Intense Pulsed light (IPL) treatment of melasma in dark skin phenotypes.
Material and Methods. The study was conducted in 32 patients of skin type IV and V. IPL with 640 nm and 690 nm filters was used. The patients were called once a month to undergo 6 sessions. Melasma area and severity index (MASI) and Clinician Global Impression Scores were used for evaluation. We followed “per protocol” analysis.
Results. Out of 26 patients who completed the treatment, 12 patients showed improvement, MASI remained unchanged in 10 patients and 4 patients showed deterioration. MASI scores before and after treatment were 6.70 ± 3.53 and 6.32 ± 3.90 (p value=0.6891). Erythema and pain were the common side effects noted. Seventeen out of 32 patients had thyroid disorders.
Conclusion. IPL should be avoided as a first line therapy in darker skin type. However, it can be used as an adjuvant therapy in some cases after careful deliberations.
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Namazi N, Hesami A, Ketabi Y. The Split-Face Comparison of the Combined Er-YAG Laser and Hydroquinone 4% With Hydroquinone 4% Alone in the Treatment of Melasma in Iranian Patients: A Prospective, Interventional Case Study. J Lasers Med Sci 2020; 11:70-73. [PMID: 32099630 DOI: 10.15171/jlms.2020.12] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Introduction: Melasma is one of the most common skin pigmentation disorders, which mostly affects the facial skin and has a considerable psychological impact on the patients. Melasma management has been one of the controversial issues in dermatology. We aimed to compare the combined treatment of the Er: YAG (erbium: yttrium-aluminum-garnet) laser plus hydroquinone (HQ) 4% with HQ 4% alone in the treatment of melasma. Methods: Twenty-nine patients were treated with the combined Er: YAG laser and HQ 4% on one side of the face with HQ 4% alone on the other side. Three sessions of the laser rat 4-week intervals. The outcome was calculated using the Melasma Area Severity Index (MASI). Results: The side that received the combined treatment (laser + HQ 4%) showed a statistically significant reduction in MASI compared to the side treated with HQ 4% alone. Conclusion: Our study suggests the superiority of the combination of the Er: YAG laser and HQ 4% in the treatment of melasma compared to HQ 4% alone.
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Affiliation(s)
- Nastaran Namazi
- Skin Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Aida Hesami
- Skin Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Yasaman Ketabi
- Skin Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Khalkhal E, Razzaghi M, Rostami-Nejad M, Rezaei-Tavirani M, Heidari Beigvand H, Rezaei Tavirani M. Evaluation of Laser Effects on the Human Body After Laser Therapy. J Lasers Med Sci 2020; 11:91-97. [PMID: 32099633 DOI: 10.15171/jlms.2020.15] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Lasers have wide applications in the treatment and diagnosis of diseases and various medical fields. Laser therapy like the other methods has advantages and disadvantages. Some risks such as bleeding, pain, and infection are created after laser therapy. Explanation and evaluation of laser effects on cell function, tissue, and the body are the aims of this study. We reviewed papers available from 1986 to 2019 about the effects of lasers on cells and tissue. An online search of PubMed, Science Direct and Google scholar using such keywords as "laser", "cell", "tissue", "body" and "side effects" was performed. The laser photons are absorbed by chromophores, resulting in the target heating and localized damage. Laser irradiation alters cellular metabolism and cellular functions. These alterations may be accompanied by undesired side effects which can be monitored via metabolites level change in the body. Based on this finding, laser therapy may be associated with several side effects and complications; therefore, before treatment, the determination of laser types and their properties is necessary to avoid creating side effects. The advantages and disadvantages of the treatment type should be considered in order to choose the best treatment with the least side effects. The patients' awareness of possible side effects before treatment and also an effective follow-up and management of patients after action are two important points in laser therapy. Training curriculum definition should be determined for laser applicant qualifications in different medical fields.
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Affiliation(s)
- Ensieh Khalkhal
- Proteomics Research Center, Faculty of Paramedical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammadreza Razzaghi
- Laser Application in Medical Sciences Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Rostami-Nejad
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Majid Rezaei-Tavirani
- Firoozabadi Hospital, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Hazhir Heidari Beigvand
- Firoozabadi Hospital, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Mostafa Rezaei Tavirani
- Proteomics Research Center, Faculty of Paramedical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Kim H, Park J, Zheng Z, Cho SB. Low-fluenced erbium:yttrium-aluminium-garnet laser treatment in combination with broadband light pretreatment for various pigmentation disorders in Asian patients. J Cosmet Dermatol 2019; 18:1657-1664. [PMID: 30825265 DOI: 10.1111/jocd.12897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 11/19/2018] [Accepted: 02/04/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Low-fluenced 2940-nm erbium (Er):yttrium-aluminium-garnet (YAG) resurfacing elicits ablative photothermal tissue reactions confined to the uppermost parts of the epidermis. OBJECTIVE To demonstrate the efficacy and safety of low-fluenced ablative Er:YAG laser treatment in combination with broadband light (BBL) pretreatment for various pigmentation disorders. METHODS In total, 35 Korean patients with various pigmentation disorders were pretreated with BBL, and then, low-fluenced Er:YAG laser resurfacing was performed with a beam size of 4 mm and a fluence of 1.0-1.5 J/cm2 . RESULTS An average of 1.1 ± 0.4 sessions of combined BBL and low-fluenced Er:YAG resurfacing treatment was delivered to the patients. Most post-Er:YAG scaling fell off spontaneously over 3-5 days, and most of the post-BBL crusting disappeared spontaneously over 5-7 days. At 2 months after final treatment, the mean global aesthetic improvement scale score for the clinical improvement of pigmentation lesions was estimated as 2.5 ± 0.8, and that for the improvement of overall skin tone, texture, and wrinkles was 2.8 ± 1.0. CONCLUSION Our data demonstrated that post-BBL, low-fluenced Er:YAG laser resurfacing can be used to effectively treat various pigmentation disorders in Asian patients. Further improvements in overall skin tone, texture, and wrinkles were also achieved without major side effects.
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Affiliation(s)
- Heesu Kim
- Department of Dermatology and Cutaneous Biology Research Center, International St. Mary's Hospital, Catholic Kwandong University College of Medicine, Incheon, Korea
| | - Jiho Park
- Department of Dermatology and Cutaneous Biology Research Center, International St. Mary's Hospital, Catholic Kwandong University College of Medicine, Incheon, Korea
| | - Zhenlong Zheng
- Department of Dermatology and Cutaneous Biology Research Center, International St. Mary's Hospital, Catholic Kwandong University College of Medicine, Incheon, Korea.,Department of Dermatology, Yanbian University Hospital, Yanji, China
| | - Sung Bin Cho
- Department of Dermatology and Cutaneous Biology Research Center, International St. Mary's Hospital, Catholic Kwandong University College of Medicine, Incheon, Korea.,Yonsei Seran Dermatology and Laser Clinic, Seoul, Korea
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14
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Jung JW, Kim WO, Jung HR, Kim SA, Ryoo YW. A Face-Split Study to Evaluate the Effects of Microneedle Radiofrequency with Q-Switched Nd:YAG Laser for the Treatment of Melasma. Ann Dermatol 2019; 31:133-138. [PMID: 33911561 PMCID: PMC7992684 DOI: 10.5021/ad.2019.31.2.133] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 05/26/2018] [Accepted: 08/30/2018] [Indexed: 12/18/2022] Open
Abstract
Background Laser toning using a low-fluence 1,064 nm Q-switched Nd:YAG laser is one of the most frequently used treatment modalities for melasma. However, this therapy is time consuming because it requires a lot of treatment sessions. Recently, it has been reported that transdermal radiofrequency (RF) is effective for the treatment of melasma. Objective To determine whether microneedle RF conduction could be an adjunct therapy for melasma, we have studied the effect of simultaneous treatments with laser toning and RF for melasma. Methods Fifteen patients with melasma underwent five sessions of laser toning and microneedle RF on the right side of the face, and only laser toning on the left side. Responses to treatments were evaluated using the Mexameter® (Courage Khazaka, Germany) score, the pigmentation and severity index (PSI) score, and the patient's overall assessment. Additionally, an electron microscopic study of a skin biopsy was performed. Results Both laser toning and combination therapy showed significant decreases in the Mexameter® and PSI score after five treatment sessions. Combination therapy showed a more significant improvement of melasma than laser toning. No remarkable side effects were reported. Electron microscopic analysis showed a greater number of vacuolar changes and increased loosening of melanocytes and adjacent epidermal cells after combination therapy. Conclusion The combination treatment of laser toning and microneedle RF therapy showed a better therapeutic effect for melasma than laser toning alone. Therefore, the microneedle RF technique could be a new and safe adjunct therapy for the treatment of melasma.
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Affiliation(s)
- Jin Woong Jung
- Department of Dermatology, Keimyung University School of Medicine, Daegu, Korea
| | - Won Oh Kim
- Department of Dermatology, Keimyung University School of Medicine, Daegu, Korea
| | - Hae Ra Jung
- Department of Pathology, Keimyung University School of Medicine, Daegu, Korea
| | - Sung Ae Kim
- Department of Dermatology, Keimyung University School of Medicine, Daegu, Korea
| | - Young Wook Ryoo
- Department of Dermatology, Keimyung University School of Medicine, Daegu, Korea
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15
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Prasad A, Sawicka KM, Pablo KB, Macri LK, Felsenstein J, Wynne JJ, Clark RA. ArF excimer laser debrides burns without destruction of viable tissue: A pilot study. Burns 2018; 44:589-595. [DOI: 10.1016/j.burns.2017.09.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 09/13/2017] [Accepted: 09/15/2017] [Indexed: 12/22/2022]
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16
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17
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Trivedi MK, Yang FC, Cho BK. A review of laser and light therapy in melasma. Int J Womens Dermatol 2017; 3:11-20. [PMID: 28492049 PMCID: PMC5418955 DOI: 10.1016/j.ijwd.2017.01.004] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 01/18/2017] [Accepted: 01/19/2017] [Indexed: 12/11/2022] Open
Abstract
Melasma is a dysregulation of the homeostatic mechanisms that control skin pigmentation and excess pigment is produced. Traditional treatment approaches with topical medications and chemical peels are commonly used but due to the refractory and recurrent nature of melasma, patients often seek alternative treatment strategies such as laser and light therapy. Several types of laser and light therapy have been studied in the treatment of melasma. Intense pulsed light, low fluence Q-switched lasers, and non-ablative fractionated lasers are the most common lasers and light treatments that are currently performed. They all appear effective but there is a high level of recurrence with time and some techniques are associated with an increased risk for postinflammatory hyper- or hypopigmentation. The number and frequency of treatments varies by device type but overall, Q-switched lasers require the greatest number of treatment applications to see a benefit. Vascular-specific lasers do not appear to be effective for the treatment of melasma. Ablative fractionated lasers should be used with caution because they have a very high risk for postinflammatory hypo- and hyperpigmentation. The use of nonablative fractionated laser treatments compared with other laser and light options may result in slightly longer remission intervals. Picosecond lasers, fractional radiofrequency, and laser-assisted drug delivery are promising future approaches to treat melasma. The goal of this review is to summarize the efficacy and safety of the most commonly used laser and light therapies to treat melasma, briefly present future laser-based treatment options for patients with melasma, and provide recommendations for treatment on the basis of the reviewed information.
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Affiliation(s)
- M K Trivedi
- University of Michigan Medical School, Ann Arbor, Michigan.,Department of Dermatology, University of California San Francisco, San Francisco, California
| | - F C Yang
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - B K Cho
- Department of Dermatology, Palo Alto Medical Foundation, Sunnyvale, California
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18
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Updates in the understanding and treatments of skin & hair disorders in women of color. Int J Womens Dermatol 2017; 3:S21-S37. [PMID: 28492036 PMCID: PMC5419061 DOI: 10.1016/j.ijwd.2017.02.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Revised: 04/15/2015] [Accepted: 04/15/2015] [Indexed: 12/19/2022] Open
Abstract
Skin of color comprises a diverse and expanding population of individuals. In particular, women of color represent an increasing subset of patients who frequently seek dermatologic care. Acne, melasma, and alopecia are among the most common skin disorders seen in this patient population. Understanding the differences in the basic science of skin and hair is imperative in addressing their unique needs. Despite the paucity of conclusive data on racial and ethnic differences in skin of color, certain biologic differences do exist, which affect the disease presentations of several cutaneous disorders in pigmented skin. While the overall pathogenesis and treatments for acne in women of color are similar to Caucasian men and women, individuals with darker skin types present more frequently with dyschromias from acne, which can be difficult to manage. Melasma is an acquired pigmentary disorder seen commonly in women with darker skin types and is strongly associated with ultraviolet (UV) radiation, genetic factors, and hormonal influences. Lastly, certain hair care practices and hairstyles are unique among women of African descent, which may contribute to specific types of hair loss seen in this population, such as traction alopecia, trichorrhexis nodosa and central centrifugal cicatricial alopecia (CCCA).
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19
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Dunbar S, Posnick D, Bloom B, Elias C, Zito P, Goldberg DJ. Energy-based device treatment of melasma: An update and review of the literature. J COSMET LASER THER 2017; 19:2-12. [DOI: 10.1080/14764172.2016.1229485] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Scott Dunbar
- Dermatology, Washington University in St. Louis, St. Louis, Missouri, USA
| | - David Posnick
- Dermatology, Palisades Medical Center, North Bergen, New Jersey, USA
| | - Bradley Bloom
- Skin Laser and Surgery Specialists of New York and New Jersey, Hackensack, New Jersey, USA
| | - Charles Elias
- Hackensack UMC Palisades, North Bergen, New Jersey, USA
| | | | - David J. Goldberg
- Director, Skin Laser and Surgery Specialists of New York and New Jersey, Westwood, New Jersey, USA
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20
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Sarkar R, Aurangabadkar S, Salim T, Das A, Shah S, Majid I, Singh M, Ravichandran G, Godse K, Arsiwala S, Arya L, Gokhale N, Sarma N, Torsekar RG, Sonthalia S, Somani VK. Lasers in Melasma: A Review with Consensus Recommendations by Indian Pigmentary Expert Group. Indian J Dermatol 2017; 62:585-590. [PMID: 29263531 PMCID: PMC5724305 DOI: 10.4103/ijd.ijd_488_17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Lasers have come up as the newest therapeutic modality in dermatological conditions including melasma. In this article, as a group of experts from Pigmentary Disorders Society in collaboration with South Asian Pigmentary Disorders Forum (SPF), we have tried to discuss the lasers which have been used in melasma and formulate simple consensus guidelines. Following thorough literature search, we have summarised the rationale of using the lasers and the supporting evidences have also been provided. It is clear that laser cannot be the first line treatment for melasma. However, it can be used as an adjuvant therapy in resistant cases, provided the selection of patient and counselling has been done properly.
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Affiliation(s)
- Rashmi Sarkar
- Department of Dermatology, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India
| | | | - T Salim
- Consultant Dermatologist, Cutis Institute of Dermatology and Aesthetic Sciences, Calicut, Kerala, India
| | - Anupam Das
- Dermatology, KPC Medical College and Hospital, Kolkata, West Bengal, India
| | - Swapnil Shah
- Consultant Dermatologist, Solapur, Maharashtra, India
| | - Imran Majid
- Dermatology, Govt Medical College, Srinagar, Kashmir, India
| | - Mohan Singh
- Consultant Dermatologist, Mohan Singh Diseases Hospital, Phagwara, Punjab, India
| | - G Ravichandran
- Senior Consultant and Coordinator, Dermatology, Apollo Hospitals, Chennai, India
| | - Kiran Godse
- Dermatology, D Y Patil Hospital, Navi Mumbai, India
| | - Shehnaz Arsiwala
- Consultant Dermatologist, Saifee Hospital, Prince Aly Khan Hospital, Mumbai, India
| | - Latika Arya
- Consultant Dermatologist, L A Skin & Aesthetic Clinic, New Delhi, India
| | - Narendra Gokhale
- Consultant Dermatologist, Sklinic Skin Clinic, Indore, Madhya Pradesh, India
| | - Nilendu Sarma
- Dermatology, Dr. B.C. Roy Postgraduate Institute of Pediatric Sciences, Kolkata, West Bengal, India
| | - R G Torsekar
- Consultant Dermatologist, Fortis Hospital, Mulund, Mumbai, India
| | - Sidharth Sonthalia
- Consultant Dermatologist, Skinnocence: The Skin Clinic, Gurgaon, Haryana, India
| | - V K Somani
- Consultant Dermatologist, Skintrendz, Himayat Nagar, Hyderabad, India
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21
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Tian WCBA. Novel technique to treat melasma in Chinese: The combination of 2940-nm fractional Er:YAG and 1064-nm Q-switched Nd:YAG laser. J COSMET LASER THER 2016; 18:72-4. [DOI: 10.3109/14764172.2015.1063662] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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22
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Lawson CN, Hollinger J, Sethi S, Rodney I, Sarkar R, Dlova N, Callender VD. Updates in the understanding and treatments of skin & hair disorders in women of color. Int J Womens Dermatol 2015; 1:59-75. [PMID: 28491960 PMCID: PMC5418751 DOI: 10.1016/j.ijwd.2015.04.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Revised: 04/15/2015] [Accepted: 04/15/2015] [Indexed: 12/19/2022] Open
Abstract
Skin of color comprises a diverse and expanding population of individuals. In particular, women of color represent an increasing subset of patients who frequently seek dermatologic care. Acne, melasma, and alopecia are among the most common skin disorders seen in this patient population. Understanding the differences in the basic science of skin and hair is imperative in addressing their unique needs. Despite the paucity of conclusive data on racial and ethnic differences in skin of color, certain biologic differences do exist, which affect the disease presentations of several cutaneous disorders in pigmented skin. While the overall pathogenesis and treatments for acne in women of color are similar to Caucasian men and women, individuals with darker skin types present more frequently with dyschromias from acne, which can be difficult to manage. Melasma is an acquired pigmentary disorder seen commonly in women with darker skin types and is strongly associated with ultraviolet (UV) radiation, genetic factors, and hormonal influences. Lastly, certain hair care practices and hairstyles are unique among women of African descent, which may contribute to specific types of hair loss seen in this population, such as traction alopecia, trichorrhexis nodosa and central centrifugal cicatricial alopecia (CCCA).
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Affiliation(s)
- Christina N Lawson
- Department of Dermatology, Howard University College of Medicine, Washington, District of Columbia.,Callender Dermatology & Cosmetic Center, Glenn Dale, Maryland
| | - Jasmine Hollinger
- Department of Dermatology, Howard University College of Medicine, Washington, District of Columbia
| | - Sumit Sethi
- Department of Dermatology, Maulana Azad Medical College and Associated Hospitals, New Delhi, India
| | - Ife Rodney
- Department of Dermatology, Howard University College of Medicine, Washington, District of Columbia
| | - Rashmi Sarkar
- Department of Dermatology, Maulana Azad Medical College and Associated Hospitals, New Delhi, India
| | - Ncoza Dlova
- Department of Dermatology, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Valerie D Callender
- Department of Dermatology, Howard University College of Medicine, Washington, District of Columbia.,Callender Dermatology & Cosmetic Center, Glenn Dale, Maryland
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23
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Rodrigues M, Pandya AG. Melasma: clinical diagnosis and management options. Australas J Dermatol 2015; 56:151-63. [DOI: 10.1111/ajd.12290] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2014] [Accepted: 11/19/2014] [Indexed: 12/01/2022]
Affiliation(s)
- Michelle Rodrigues
- Department of Dermatology; St Vincent's Hospital; Melbourne Victoria
- Department of Dermatology; The Royal Children's Hospital; Melbourne
- The Skin and Cancer Foundation; Inc
| | - Amit G Pandya
- Department of Dermatology; University of Texas; Southwestern Medical Centre; Dallas Texas USA
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24
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Vachiramon V, Sirithanabadeekul P, Sahawatwong S. Low-fluence Q-switched Nd: YAG 1064-nm laser and intense pulsed light for the treatment of melasma. J Eur Acad Dermatol Venereol 2014; 29:1339-46. [DOI: 10.1111/jdv.12854] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Accepted: 06/17/2014] [Indexed: 12/12/2022]
Affiliation(s)
- V. Vachiramon
- Ramathibodi Laser Center; Division of Dermatology; Ramathibodi Hospital; Mahidol University; Bangkok Thailand
| | - P. Sirithanabadeekul
- Ramathibodi Laser Center; Division of Dermatology; Ramathibodi Hospital; Mahidol University; Bangkok Thailand
| | - S. Sahawatwong
- Ramathibodi Laser Center; Division of Dermatology; Ramathibodi Hospital; Mahidol University; Bangkok Thailand
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25
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Evidence-based treatment for melasma: expert opinion and a review. Dermatol Ther (Heidelb) 2014; 4:165-86. [PMID: 25269451 PMCID: PMC4257945 DOI: 10.1007/s13555-014-0064-z] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Indexed: 11/17/2022] Open
Abstract
Introduction Melasma is one of the most common pigmentary disorders seen by dermatologists and often occurs among women with darker complexion (Fitzpatrick skin type IV–VI). Even though melasma is a widely recognized cause of significant cosmetic disfigurement worldwide and in India, there is a lack of systematic and clinically usable treatment algorithms and guidelines for melasma management. The present article outlines the epidemiology of melasma, reviews the various treatment options along with their mode of action, underscores the diagnostic dilemmas and quantification of illness, and weighs the evidence of currently available therapies. Methods A panel of eminent dermatologists was created and their expert opinion was sought to address lacunae in information to arrive at a working algorithm for optimizing outcome in Indian patients. A thorough literature search from recognized medical databases preceded the panel discussions. The discussions and consensus from the panel discussions were drafted and refined as evidence-based treatment for melasma. The deployment of this algorithm is expected to act as a basis for guiding and refining therapy in the future. Results It is recommended that photoprotection and modified Kligman’s formula can be used as a first-line therapy for up to 12 weeks. In most patients, maintenance therapy will be necessary with non-hydroquinone (HQ) products or fixed triple combination intermittently, twice a week or less often. Concomitant camouflage should be offered to the patient at any stage during therapy. Monthly follow-ups are recommended to assess the compliance, tolerance, and efficacy of therapy. Conclusion The key therapy recommended is fluorinated steroid containing 2–4% HQ-based triple combination for first line, with additional selective peels if required in second line. Lasers are a last resort. Electronic supplementary material The online version of this article (doi:10.1007/s13555-014-0064-z) contains supplementary material, which is available to authorized users.
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26
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Attwa E, Khater M, Assaf M, Haleem MA. Melasma treatment using an erbium:YAG laser: a clinical, immunohistochemical, and ultrastructural study. Int J Dermatol 2014; 54:235-44. [DOI: 10.1111/ijd.12477] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Enayat Attwa
- Department of Dermatology and Venereology; Faculty of Medicine; Zagazig University; Zagazig Egypt
| | - Mohamed Khater
- Department of Dermatology and Venereology; Faculty of Medicine; Zagazig University; Zagazig Egypt
| | - Magda Assaf
- Department of Pathology; Faculty of Medicine; Zagazig University; Zagazig Egypt
| | - Manal Abdel Haleem
- Department of Histology; Faculty of Medicine; Zagazig University; Zagazig Egypt
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27
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Been MJ, Mangat DS. Laser and Face Peel Procedures in Non-Caucasians. Facial Plast Surg Clin North Am 2014; 22:447-52. [DOI: 10.1016/j.fsc.2014.04.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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28
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Berardesca E, Ardigò M, Berardesca M, Cameli N. Melasma: current and future treatments. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/17469872.3.2.187] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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29
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Hilton S, Heise H, Buhren BA, Schrumpf H, Bölke E, Gerber PA. Treatment of melasma in Caucasian patients using a novel 694-nm Q-switched ruby fractional laser. Eur J Med Res 2013; 18:43. [PMID: 24225160 PMCID: PMC3831591 DOI: 10.1186/2047-783x-18-43] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Accepted: 10/29/2013] [Indexed: 11/12/2022] Open
Abstract
Background Melasma is a common hypermelanosis of the face. The use of a classical Q-switched ruby laser (QSRL) to treat melasma is discussed controversially and is associated with frequent adverse effects, such as hyper- or hypopigmentation. Recently a fractional-mode (FRx) QSRL was developed to minimize the adverse effects of classical QSRL. The objective of this research was to evaluate the efficacy and safety of a novel FRx-QSRL in the treatment of melasma in Caucasian patients. Methods We performed a retrospective study of 25 Caucasian melasma patients (Fitzpatrick skin types I to III). Patients received one to three FRx-QSRL treatments (Tattoostar FRx, Asclepion Laser Technologies, Jena, Germany) at pulse energies of 4 to 8 J/cm2. Three blinded investigators independently evaluated the melasma area and severity index (MASI) score before treatment and at the four- to six-week follow-ups. At additional three-month follow-ups, patients evaluated subjective improvement, pain and over-all satisfaction with the treatment according to a numeric analogue score (NAS). Side effects were documented. Results At four to six weeks post laser treatment for a mean of 1.4 sessions, we observed a significant (P = 0.0001) reduction of the MASI score from 6.54 to 1.98 (72.3%). Patients rated the pain of the intervention at a mean 2.46 points (0 = no pain; 10 = maximum pain), the improvement at a mean 5.55 points (0 = no improvement; 10 = maximum improvement) and the overall satisfaction at a mean 4.66 points (0 = not satisfied; 10 = maximum satisfaction). After three months, post-inflammatory hyperpigmentation (PIH) and/or recurring melasma were observed in 7 (28%) and 11 (44%) patients, respectively. Conclusion The 694-nm FRx-QSRL is a safe and effective option for treating melasma in Caucasian patients. Over periods of >3 months, PIH and/or recurring melasma may develop at significant rates and may reduce patient satisfaction. Multiple treatment sessions with lower pulse energies and/or a post-interventional therapy with hypopigmenting ointments and UV protection may help to minimize these complications.
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30
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Morais OOD, Lemos ÉFL, Sousa MCDS, Gomes CM, Costa IMC, Paula CDRD. The use of ablative lasers in the treatment of facial melasma. An Bras Dermatol 2013; 88:238-42. [PMID: 23739704 PMCID: PMC3750887 DOI: 10.1590/s0365-05962013000200009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Accepted: 06/25/2012] [Indexed: 11/21/2022] Open
Abstract
Melasma represents a pigmentary disorder that is difficult to treat. This study aims to broadly review the use of ablative lasers (Er:YAG and CO2) in the treatment of melasma, presenting the level of evidence of studies published to date. A total of 75 patients were enrolled in four case series studies (n=39), one controlled clinical trial (n=6) and one randomized controlled clinical trial (n=30). Studies on the Er:YAG laser showed better results with the use of short square-shaped pulses, which determined low rates of post-inflammatory hyperpigmentation and long-lasting maintenance of results. Likewise, studies on the CO2 laser proved the benefits of short pulse duration along with low-density energy. Post-treatment maintenance with the use of antipigmenting creams was necessary and effective to sustain long-term results. Ablative lasers may represent another useful and effective tool against melasma. Postinflammatory hyperpigmentation and difficulty in sustaining long-term results still represent the main limitations to a broader use of ablative lasers. Based on actual evidence, the use of this technology should be restricted to patients with recalcitrant disease. Further studies will help establish optimal laser parameters and treatment regimens.
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31
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Fabbrocini G, De Vita V, Marasca C, Palmisano F, Monfrecola G. Salicylic acid for the treatment of melasma: new acquisitions for monitoring the clinical improvement. Skin Res Technol 2013; 19:466-73. [PMID: 23527534 DOI: 10.1111/srt.12070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2013] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The Melasma Area and Severity Index (MASI) and the Melasma Severity Score (MSS) are calculated on the basis of only a subjective clinical assessment. This raises the need to have an objective score, uniform in the evaluation by different clinicians. The purpose of this study was to establish if the images by Canfield Reveal Imager can be correlated to MASI score to better evaluate the clinical efficacy of salicylic acid 33% peeling in the treatment of melasma respect to the clinical observation. METHODS The study was a voluntary observational study. Twenty female patients affected with melasma, aged between 30 and 60 years, were included in the study. Treatment with salicylic acid 33% was performed once a month, for a total of four times. The dermatologist (Doc A) examined each patient's melasma areas using MASI score, at the face-to-face observation and at Reveal images evaluation during the first (T0) and the end point time (T4). Digital photographs were also evaluated by another experienced dermatologist (Doc B), who has never seen clinically the patients before and who evaluated MASI score by Reveal images at time T0 and T4. RESULTS Student's t-test and linear regression test were performed, showing statistically significant values comparing MASI score obtained by digital photo and MASI score obtained clinically. CONCLUSION The monitoring of the improvement by Reveal images can optimize the treatment approach and the efficacy of same dermocosmetics procedures can be revised following standard criteria.
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Affiliation(s)
- Gabriella Fabbrocini
- Department of Clinical Medicine and Surgery, Section of Dermatology, University Federico II of Naples, Naples, Italy
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32
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Park KY, Oh IY, Moon NJ, Seo SJ. Treatment of infraorbital dark circles in atopic dermatitis with a 2790-nm erbium: yttrium scandium gallium garnet laser: A pilot study. J COSMET LASER THER 2013; 15:102-6. [DOI: 10.3109/14764172.2012.759236] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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33
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Sim JH, Park YL, Lee JS, Lee SY, Choi WB, Kim HJ, Lee JH. Treatment of melasma by low-fluence 1064 nm Q-switched Nd:YAG laser. J DERMATOL TREAT 2013; 25:212-7. [PMID: 23030603 DOI: 10.3109/09546634.2012.735639] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Ji Hoon Sim
- Department of Dermatology, College of Medicine, Soonchunhyang University , Seoul , Korea
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34
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Ho SGY, Yeung CK, Chan NPY, Shek SY, Chan HHL. A retrospective study of the management of Chinese melasma patients using a 1927 nm fractional thulium fiber laser. J COSMET LASER THER 2013; 15:200-6. [DOI: 10.3109/14764172.2012.761346] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Stephanie G Y Ho
- Division of Dermatology, Department of Medicine, The University of Hong Kong, Hong Kong SAR, China.
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35
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Wanitphakdeedecha R, Keoprasom N, Eimpunth S, Manuskiatti W. The efficacy in melasma treatment using a 1410 nm fractional photothermolysis laser. J Eur Acad Dermatol Venereol 2013; 28:293-7. [PMID: 23347253 DOI: 10.1111/jdv.12100] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2012] [Accepted: 12/19/2012] [Indexed: 11/30/2022]
Abstract
BACKGROUND Melasma treatment modalities including topical and procedural therapy have been employed with variable results and high recurrence rate. OBJECTIVE To quantitatively assess improvement in melasma and side effects after 1410 nm fractional photothermolysis laser treatments and to determine efficacy at 1-, 2- and 3-month follow-up after treatment. METHODS Thirty volunteers with melasma were treated with 1410 nm fractional photothermolysis for four passes on full face and additional four passes on melasma area. They were randomly treated on one side of their face with 20 mJ at 5% coverage and the other side of their face with 20 mJ at 20% coverage. All subjects were treated monthly for five times. Melanin index, Visual analogue scale and Melasma Area and Severity Index score were measured at baseline and 1-, 2- and 3-month follow-up after complete treatment protocol. RESULTS There was statistically significant improvement of Melanin index at 2- and 3-month follow-up visits, but not at 1-month follow-up visit. Visual analogue scale and Melasma Area and Severity Index score improved significantly on both sides at 1-, 2- and 3-month follow-ups. The overall patients' satisfaction was significantly higher on the side treated with 20 mJ, 5% coverage. Adverse reactions included erythema, dryness and post-inflammatory hyperpigmentation on melasma area. Those side effects were significantly more intense on the side treated with 20 mJ, 20% coverage. CONCLUSIONS 1410 nm fractional photothermolysis laser treatment is a safe and temporary effective procedure for melasma; however, long-term follow-up is still needed. Only 5% coverage should be used to minimize risks of adverse effects.
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Affiliation(s)
- R Wanitphakdeedecha
- Department of Dermatology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Niwa Massaki ABM, Eimpunth S, Fabi SG, Guiha I, Groff W, Fitzpatrick R. Treatment of melasma with the 1,927-nm fractional thulium fiber laser: A retrospective analysis of 20 cases with long-term follow-up. Lasers Surg Med 2012; 45:95-101. [DOI: 10.1002/lsm.22100] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2012] [Indexed: 11/05/2022]
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Arora P, Sarkar R, Garg VK, Arya L. Lasers for treatment of melasma and post-inflammatory hyperpigmentation. J Cutan Aesthet Surg 2012; 5:93-103. [PMID: 23060704 PMCID: PMC3461803 DOI: 10.4103/0974-2077.99436] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Hyperpigmentary disorders, especially melasma and post-inflammatory hyperpigmentation (PIH), cause significant social and emotional stress to the patients. Although many treatment modalities have been developed for melasma and PIH, its management still remains a challenge due to its recurrent and refractory nature. With the advent of laser technology, the treatment options have increased especially for dermal or mixed melasma. To review the literature on the use of cutaneous lasers for melasma and PIH. We carried out a PubMed search using following terms “lasers, IPL, melasma, PIH”. We cited the use of various lasers to treat melasma and PIH, including Q-switched Nd:YAG, Q-switched alexandrite, pulsed dye laser, and various fractional lasers. We describe the efficacy and safety of these lasers for the treatment of hyperpigmentation. Choosing the appropriate laser and the correct settings is vital in the treatment of melasma. The use of latter should be restricted to cases unresponsive to topical therapy or chemical peels. Appropriate maintenance therapy should be selected to avoid relapse of melasma.
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Affiliation(s)
- Pooja Arora
- Chacha Nehru Bal Chikitsalaya, Geeta Colony, Delhi, India
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Ferraq Y, Black DR, Theunis J, Mordon S. Superficial wounding model for epidermal barrier repair studies: comparison of Erbium:YAG laser and the suction blister method. Lasers Surg Med 2012; 44:525-32. [PMID: 22865469 DOI: 10.1002/lsm.22054] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2012] [Indexed: 11/09/2022]
Abstract
BACKGROUND AND OBJECTIVES Wound-healing studies use mainly mechanical methods for wound induction, which are laborious and difficult to standardize. Objective of this study was to evaluate the Erbium:Yttrium-Aluminium-Garnet (Er:YAG) laser method as a model of epidermis ablation on human skin in vivo and to compare the quality and healing rates of Er:YAG laser and suction blister (SB) wounds. MATERIALS AND METHODS Er:YAG laser and SB wounds were made on the forearms of 10 healthy volunteers. Post-wounding measurements including wound surface area (WSA) from photographs, wound depth from 3D volume analysis, trans-epidermal water loss (TEWL), laser doppler blood flow (LDBF), and optical coherence tomography (OCT) imaging were made daily over 7 days. Biopsies were taken on Days 4 and 7. RESULTS 3D analysis showed laser wounds to be shallower and more uniform in depth than SB: 54 ± 14 µm versus 140 ± 102 µm, respectively, with histology demonstrating complete epidermal removal using SB. SB wounds were more variable in size with a WSA of 0.47 ± 0.24 cm(2) compared to 1.17 ± 0.14 cm(2) for laser wounds. Healing rates were similar in both groups, as measured by TEWL, LDBF, and WSA. OCT imaging on Days 3-4 revealed new epidermis below the fibrin clot, similar to histology, and a visible stratum corneum on Day 7, but no apparent epidermal hyperplasia in contrast to histology. CONCLUSION Compared to the SB model, Er:YAG laser achieved rapid standardized epidermal ablation, which despite morphological differences, was similar in terms of epidermal regeneration/barrier formation.
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Affiliation(s)
- Younes Ferraq
- Skin Research Centre, Pierre Fabre Dermocosmétique, Hotel Dieu, Toulouse, France
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Treatment of melasma with oral administration of tranexamic acid. Aesthetic Plast Surg 2012; 36:964-70. [PMID: 22552446 DOI: 10.1007/s00266-012-9899-9] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2011] [Accepted: 03/11/2012] [Indexed: 11/27/2022]
Abstract
BACKGROUND Melasma is a common pigmentary disorder among Asian women. The available therapies such as bleaching agents, chemical peeling, laser, and intense pulsed light are not satisfactory or safe. In the search to find a new treatment therapy for melasma, oral administration of tranexamic acid (TA) was studied clinically in Chinese patients. METHODS The study enrolled 74 patients. Tranexamic acid tablets were prescribed at a dosage of 250 mg twice daily for a therapeutic period of 6 months. All the patients were followed up for more than 6 months after the treatment. The effects of treatment were evaluated by two physicians independently and by the patient based on improvement of pigmentation and reduction in melasma size. These were graded into four levels: excellent, good, fair, and poor. RESULTS After 6 months of treatment, the effects were graded as follows: excellent (10.8%, 8/74), good (54%, 40/74), fair (31.1%, 23/74), and poor (4.1%, 3/74). Side effects of TA such as gastrointestinal discomfort (5.4%) and hypomenorrhea (8.1%) were observed, but no severe complications were found. The recurrence of melasma was observed in seven cases (9.5%). CONCLUSIONS Oral administration of TA is an effective and safe therapy for the treatment of melasma. LEVEL OF EVIDENCE II This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors at www.springer.com/00266.
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Kauvar AN. The Evolution of Melasma Therapy: Targeting Melanosomes Using Low-Fluence Q-Switched Neodymium-Doped Yttrium Aluminium Garnet Lasers. ACTA ACUST UNITED AC 2012; 31:126-32. [DOI: 10.1016/j.sder.2012.02.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Revised: 02/17/2012] [Accepted: 02/17/2012] [Indexed: 10/28/2022]
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Kauvar ANB. Successful treatment of melasma using a combination of microdermabrasion and Q-switched Nd:YAG lasers. Lasers Surg Med 2012; 44:117-24. [PMID: 22334295 DOI: 10.1002/lsm.21156] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2011] [Indexed: 11/05/2022]
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Affiliation(s)
- Virendra N Sehgal
- Dermato Venereology Center, Sehgal Nursing Home, Panchwati, Delhi, India.
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Affiliation(s)
- Vaneeta M Sheth
- Department of Dermatology at Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Amit G Pandya
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas.
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Karsai S, Fischer T, Pohl L, Schmitt L, Buhck H, Jünger M, Raulin C. Is non-ablative 1550-nm fractional photothermolysis an effective modality to treat melasma? Results from a prospective controlled single-blinded trial in 51 patients. J Eur Acad Dermatol Venereol 2011; 26:470-6. [DOI: 10.1111/j.1468-3083.2011.04100.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- S Karsai
- Laser Clinic Karlsruhe, Karlsruhe, Germany.
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Barysch M, Rümmelein B, Kolm I, Karpova M, Schönewolf N, Bogdan Allemann I, Dummer R. Split-face study of melasma patients treated with non-ablative fractionated photothermolysis (1540 nm). J Eur Acad Dermatol Venereol 2011; 26:423-30. [DOI: 10.1111/j.1468-3083.2011.04086.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Y a-t-il une place pour le laser dans le traitement du mélasma ? Ann Dermatol Venereol 2011; 138:319-20. [DOI: 10.1016/j.annder.2010.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2010] [Accepted: 12/30/2010] [Indexed: 11/22/2022]
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Lee WR, Shen SC, Al-Suwayeh SA, Yang HH, Yuan CY, Fang JY. Laser-assisted topical drug delivery by using a low-fluence fractional laser: imiquimod and macromolecules. J Control Release 2011; 153:240-8. [PMID: 21435360 DOI: 10.1016/j.jconrel.2011.03.015] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2010] [Revised: 01/17/2011] [Accepted: 03/13/2011] [Indexed: 12/18/2022]
Abstract
The aim of this study was to evaluate the ability of a low-fluence fractional erbium:yttrim-aluminum-garnet (Er:YAG) laser, with a wavelength of 2940 nm, for enhancing and controlling the skin permeation of imiquimod and macromolecules such as polypeptides and fluorescein isothiocyanate (FITC)-labeled dextran (FD). The in vitro permeation has been determined using a Franz diffusion cell, with porcine skin and nude mouse skin as the barriers. Hyperproliferative and ultraviolet (UV)-irradiated skins were also used as barrier models to mimic the clinical therapeutic conditions. Confocal laser scanning microscopy (CLSM) was used to examine the in vivo nude mouse skin uptake of peptide, FITC, and FD. Both in vitro and in vivo results indicated an improvement in permeant skin delivery by the laser. The laser fluence and number of passes were found to play important roles in controlling drug transport. Increases of 46- and 127-fold in imiquimod flux were detected using the respective fluences of 2 and 3 J/cm(2) with 4 pulses. An imiquimod concentration of 0.4% from aqueous vehicle with laser treatment was sufficient to approximate the flux from the commercial cream with an imiquimod dose of 5% without laser treatment, indicating a reduction of the drug dose by 125-fold. The enhancement of peptide permeation was size and sequence dependent, with the smaller molecular weight (MW) and more-hydrophilic entities showing greater enhancing effect. Skin permeation of FD with an MW of at least 150 kDa could be achieved with fractional laser irradiation. CLSM images revealed intense green fluorescence from the permeants after exposure of the skin to the laser. The follicular pathway was significant in laser-assisted permeation.
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Affiliation(s)
- Woan-Ruoh Lee
- Graduate Institute of Clinical Medicine, Taipei Medical University, Taipei 110, Taiwan
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Chan NPY, Ho SGY, Shek SYN, Yeung CK, Chan HH. A case series of facial depigmentation associated with low fluence q-switched 1,064 nm Nd:YAG laser for skin rejuvenation and melasma. Lasers Surg Med 2010; 42:712-9. [PMID: 20848553 DOI: 10.1002/lsm.20956] [Citation(s) in RCA: 104] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Nicola P Y Chan
- Division of Dermatology, Department of Medicine, University of Hong Kong, Hong Kong SAR, China
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Polnikorn N. Treatment of refractory melasma with the MedLite C6 Q-switched Nd:YAG laser and alpha arbutin: a prospective study. J COSMET LASER THER 2010; 12:126-31. [PMID: 20482238 DOI: 10.3109/14764172.2010.487910] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of a Q-switched Nd:YAG laser (MedLite C6; HOYA ConBio, Fremont, CA, USA) and 7% alpha arbutin solution (Skin Advance Laboratory, Japan) in the treatment of melasma. METHODS This was a prospective study of 35 refractory melasma cases treated with 10 weekly laser sessions, two monthly follow-up treatments and topical 7% alpha arbutin solution. Clinical photographs and severity grading on a 5-point scale were carried out by an independent observer at each visit. RESULTS At 6 months, 30% of study subjects received results in the excellent clearance category (> 81% reduction of melasma) and 36.7% received good (51-80% reduction) clearance. Mild and transient side effects included discomfort during treatment, erythema, whitening of fine hair and urticaria. Three cases of mottling hypo-pigmentation (8.57%) and two cases of recurrence of melasma (5.71%) were recorded. CONCLUSION Combination therapy with the MedLite C6 and 7% alpha arbutin solution is an effective and well-tolerated treatment for refractory melasma.
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Affiliation(s)
- Niwat Polnikorn
- Kasemrad Aesthetic Center, Kasemrad Prachacheun Hospital, Bangsue, Bangkok, Thailand.
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Abstract
Today, laser therapy is standard treatment for a wide variety of dermatologic complaints. From skin rejuvenation to the management of complex vascular malformations, laser treatment has proved to be an effective, innovative solution to once-challenging dilemmas. However, laser application in those with darker complexions remains a topic of great concern. Although contemporary devices may use longer-wavelength lasers and cooling devices to isolate target tissues within patients with high levels of epidermal melanin, significant risk remains. Today's laser surgeon must have a thorough understanding of patient concerns, lesion character and response to treatment, as well as the unique needs of those with darker skin. In this article, we discuss critical issues in patient assessment, proper evaluation of common skin complaints, and laser therapy use for a variety of lesions in the ethnic population.
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Affiliation(s)
- Patrick D Cole
- Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas
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