The efficacy in melasma treatment using a 1410 nm fractional photothermolysis laser

An Update on New and Existing Treatments for the Management of Melasma

Melasma is a chronic, acquired disorder of focal hypermelanosis that carries significant psychosocial impact and is challenging for both the patient and the treating practitioner to manage in the medium to long term. Multiple treatments have been explored, often in combination given the many aetiological factors involved in its pathogenesis. Therapeutic discoveries to treat melasma are a focal topic in the literature and include a range of modalities, with recent developments including updates on visible light photoprotection, non-hydroquinone depigmenting agents, oral tranexamic acid, chemical peels, and laser and energy-based device therapy for melasma. It is increasingly important yet challenging to remain up-to-date on the arsenal of treatments available for melasma to find an efficacious and well-tolerated option for our patients.

Medical therapies for Melasma

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.

Laser treatment of medical skin disease in women

Laser treatment is a relatively new and increasingly popular modality for the treatment of many dermatologic conditions. A number of conditions that predominantly occur in women and that have a paucity of effective treatments include rosacea, connective tissue disease, melasma, nevus of Ota, lichen sclerosus (LS), notalgia paresthetica and macular amyloidosis, and syringomas. Laser therapy is an important option for the treatment of patients with these conditions. This article will review the body of literature that exists for the laser treatment of women with these medical conditions.

The use of sunscreen starting on the first day after ablative fractional skin resurfacing

BACKGROUND

The most common side-effect of ablative fractional skin resurfacing in Asians is post inflammatory hyperpigmentation (PIH). Various attempts have been made to reduce the occurrence of PIH after laser treatment including sun avoidance, the use of preoperative and postoperative treatment regimens, and treatment using conservative energy settings and epidermal protection.

OBJECTIVES

To determine whether the use of broad-spectrum sunscreen with anti-inflammatory agents starting on the first day after fractional CO2 laser skin resurfacing reduces the incidence of post laser PIH.

MATERIALS AND METHODS

Thirty patients were treated with ablative fractional CO2 resurfacing on both sides of their faces at 10 mJ and 10% density. Each subject was randomly treated on one side of the face with petrolatum ointment four times a day for the first week after laser treatment and on the other side of the face with petrolatum ointment four times a day plus broad-spectrum sunscreen with anti-inflammatory agents in the morning starting on the first day after laser treatment. Transepidermal water loss was recorded at baseline and every day for 1 week. Melanin and erythema indexes were measured at baseline, 1-, 2-week, 1-, 2- and at 3-month post treatment.

RESULTS

Of the 30 patients involved in the study, 26 received the treatment and attended 1-, 2-week, 1-, 2- and 3-month post-treatment visits. Four patients were withdrawn from the study because they could not attend every follow-up visit. There was no statistically significant difference in transepidermal water loss at baseline, immediately after laser treatment, or at the D1 to D7 follow-up visits. Erythema index had no significantly statistical difference at baseline, 1-, 2- and at 3-month after laser treatment. Furthermore, there was a statistically significant difference in melanin index at 1-week post laser treatment between both sides (P = 0.001). Melanin index at the 1-week follow-up visit on the side treated with broad-spectrum sunscreen with anti-inflammatory agents starting on the first day after laser treatment was significantly less than the control side.

CONCLUSION

The use of broad-spectrum sunscreen with anti-inflammatory agents starting on the first day after ablative fractional skin resurfacing can decrease the incidence of PIH after laser treatment at 1-week postoperatively.