Low-fluence Q-switched Nd: YAG 1064-nm laser and intense pulsed light for the treatment of melasma

Novel 532-nm Q-switched Nd: YAG laser for the treatment of melasma and rejuvenation: a prospective, randomized controlled comparison with 1,064-nm Q-switched Nd: YAG laser

BACKGROUND

Melasma is a common pigmentary and photoaging disorder. Although various treatments, including 1,064-nm Q-switched neodymium-doped yttrium aluminum garnet (QS-Nd: YAG) laser toning, are available for melasma, results are often unsatisfactory.

OBJECTIVE

We aimed to determine the efficacy and safety of 532-nm QS-Nd: YAG laser (shortwave toning) in patients with melasma and facial rejuvenation.

METHODS

Fifty-two patients were recruited to receive either 1,064-nm QS-Nd: YAG laser or 532-nm QS-Nd: YAG laser every 2 weeks for 8 sessions and a 2-month follow-up visit in a randomized controlled double-blinded study. The primary outcome measure was the Melasma Area and Severity Index (MASI) score. Dermoscope and high-frequency ultrasound (HFUS) were used to assess the improvement of melasma and photoaging.

RESULTS

532-nm QS-Nd: YAG laser achieved significantly higher improvement in the MASI score (P = 0.000). The Dermoscopic melasma score (DMS) displayed significant change and confirmed the improvement. HFUS showed a significant decrease in the thickness of the subepidermal low-echogenic band (SLEB) and increases in dermal thickness and dermal density in both groups (P = 0.000 for all). The rate of very satisfied responses was significantly higher in the 532-nm laser group (P = 0.001). There was no significant difference in the visual analog scale pain assessment score (P = 0.248) and recurrence rate (P = 0.734) between the two groups.

CONCLUSION

532-nm QS-Nd: YAG laser (shortwave toning) proved to be an effective and safe treatment for melasma and rejuvenation. Shortwave toning was significantly better for pigmentation clearance, while 1,064-nm laser showed better improvement in skin rejuvenation.

Combining large-spot low-fluence 1064-nm and fractional 1064-nm picosecond lasers for promoting protective melanosome autophagy via the PI3K/Akt/mTOR signalling pathway for the treatment of melasma

Melasma is a common condition of hyperpigmented facial skin. Picosecond lasers are reported to be effective for the treatment of melasma. We aimed to identify the most effective therapeutic mode and elucidate the potential molecular mechanisms of picosecond lasers for the treatment of melasma. Female Kunming mice with melasma-like conditions were treated using four different picosecond laser modes. Concurrently, in vitro experiments were conducted to assess changes in melanin and autophagy in mouse melanoma B16-F10 cells treated with these laser modes. Changes in melanin in mouse skin were detected via Fontana-Masson staining, and melanin particles were evaluated in B16-F10 cells. Real-time polymerase chain reaction and western blotting were used to analyse the expression levels of melanosome and autophagy-related messenger ribonucleic acid (mRNA) and proteins. A combination of large-spot low-fluence 1064-nm and fractional 1064-nm picosecond lasers resulted insignificant decreases in melanin as well as in mRNA and protein expression of melanin-synthesizing enzymes (TYR, TRP-1 and MITF). This combination also led to increased expression of the autophagy-related proteins, Beclin1 and ATG5, with a marked decrease in p62 expression. Intervention with the PI3K activator, 740 Y-P, increased TYR, TRP-1, MITF, p-PI3K, p-AKT, p-mTOR and p62 expression but decreased the expression of LC3, ATG5 and Beclin1. A combination of large-spot low-fluence 1064-nm and fractional 1064-nm picosecond lasers proved more effective and safer. It inhibits melanin production, downregulates the PI3K/AKT/mTOR pathway, enhances melanocyte autophagy and accelerates melanin metabolism, thereby reducing melanin content.

Management of Melasma: Laser and Other Therapies-Review Study

Melasma is a commonly occurring pigmented skin condition that can significantly affect one's appearance, described as symmetric hyperpigmentation that presents as irregular brown to gray-brown macules on various facial areas, such as the cheeks, forehead, nasal bridge, and upper lip, along with the mandible and upper arms. Due to its complex pathogenesis and recurrent nature, melasma management is challenging and the outcomes following treatment are not always deemed satisfactory. Solely treating hyperpigmentation may prove ineffective unless paired with regenerative techniques and photoprotection, since one of the main reasons for recurrence is sun exposure. Hence, the treatment protocol starts with addressing risk factors, implementing stringent UV protection, and then treatment using different strategies, like applying topical treatments, employing chemical peels, laser and light therapies, microneedling, and systemic therapy. This review aims to provide a summary of the effectiveness and safety of the frequently employed laser and light therapies for treating melasma, focusing on laser therapy as a treatment for melasma.

Q-switched 1064 nm Nd: YAG laser restores skin photoageing by activating autophagy by TGFβ1 and ITGB1

Excessive ultraviolet B ray (UVB) exposure to sunlight results in skin photoageing. Our previous research showed that a Q-switched 1064 nm Nd: YAG laser can alleviate skin barrier damage through miR-24-3p. However, the role of autophagy in the laser treatment of skin photoageing is still unclear. This study aims to investigate whether autophagy is involved in the mechanism of Q-switched 1064 nm Nd: YAG in the treatment of skin ageing. In vitro, primary human dermal fibroblast (HDF) cells were irradiated with different doses of UVB to establish a cell model of skin photoageing. In vivo, SKH-1 hairless mice were irradiated with UVB to establish a skin photoageing mouse model and irradiated with laser. The oxidative stress and autophagy levels were detected by western blot, immunofluorescence and flow cytometer. String was used to predict the interaction protein of TGF-β1, and CO-IP and GST-pull down were used to detect the binding relationship between TGFβ1 and ITGB1. In vitro, UVB irradiation reduced HDF cell viability, arrested cell cycle, induced cell senescence and oxidative stress compared with the control group. Laser treatment reversed cell viability, senescence and oxidative stress induced by UVB irradiation and activated autophagy. Autophagy agonists or inhibitors can enhance or attenuate the changes induced by laser treatment, respectively. In vivo, UVB irradiation caused hyperkeratosis, dermis destruction, collagen fibres reduction, increased cellular senescence and activation of oxidative stress in hairless mice. Laser treatment thinned the stratum corneum of skin tissue, increased collagen synthesis and autophagy in the dermis, and decreased the level of oxidative stress. Autophagy agonist rapamycin and autophagy inhibitor 3-methyladenine (3-MA) can enhance or attenuate the effects of laser treatment on the skin, respectively. Also, we identified a direct interaction between TGFB1 and ITGB1 and participated in laser irradiation-activated autophagy, thereby inhibiting UVB-mediated oxidative stress further reducing skin ageing. Q-switched 1064 nm Nd: YAG laser treatment inhibited UVB-induced oxidative stress and restored skin photoageing by activating autophagy, and TGFβ1 and ITGB1 directly incorporated and participated in this process.

Efficacy and safety of laser-related therapy for melasma: A systematic review and network meta-analysis

BACKGROUND

Melasma is a prevalent, persistent hyperpigmentation disorder that negatively affects the psychological health of patients. However, the treatment outcome remains unsatisfactory due to the complexity of pathogenesis, recurrence characteristics, and relatively high morbidity.

OBJECTIVES

To compare the performance of laser-related therapies in improving the melasma area severity index (MASI) score of melasma and the occurrence of adverse effects by network meta-analysis (NMA).

METHODS

From the inception to November 2022, eligible randomized controlled trials were identified. Two investigators independently searched relevant studies from PUBMED, EMBASE, and the Cochrane Library database.

RESULTS

A total of 39 clinical studies with 1394 participants were eligible for enrollment. For efficacy, the NMA demonstrated that Q-switched Nd: YAG laser + topical medications (QSND+TM) was superior to Q-switched Nd:YAG laser (QSND) [MD = -4.21 (-6.80, -1.63)], Er: YAG laser + topical medications (ERYL+TM) [MD = -3.52 (-6.84, -0.19)], and picosecond laser + topical medications (PICO+TM) [MD = -4.80 (-9.33, -0.27)]. The microneedling + topical medications (MN+TM) was superior to picosecond laser (PICO) [MD = -5.26 (-10.44, -0.08)] and topical medications (TM) [MD = -5.22 (-9.20, -1.23)]. The top five of the surface under the cumulative ranking curve value (SUCRA) are Q-switched Nd:YAG laser + topical medications (QSND+TM 85.9%), oral tranexamic acid (oTA 80.1%), microneedling + topical medications (MN+TM 79.7%), Q-switched Nd:YAG laser + intense pulse light (QSND+IPL 78.9%), and fractional carbon dioxide laser + topical medications (FCDL+TM 70.5%).

CONCLUSIONS

In conclusion, the Qs-Nd:YAG laser with topical medications is the first choice for treating melasma according to the SUCRA value. Among the three treatment modalities, namely MN + TM, PICO, and TM, our recommendation favors MN+TM as the superior choice for enhancing the curative efficacy in melasma. However, the actual clinical choice should also take into account the adverse effects, the skin type of the patient, the duration of the disease, and other relevant factors.

Efficacy and Safety of Picosecond Laser in the Treatment of Melasma: A Network Meta-analysis

BACKGROUND

The role of lasers in the treatment of melasma and acquired hyperpigmentation disease of the skin has been suggested by clinicians. However, there is no consensus on the most efficient and safe treatment method.

OBJECTIVE

To systematically evaluate the efficacy and safety of picosecond laser in the treatment of melasma.

METHODS AND MATERIALS

PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure, Chinese scientific journal database, and Wanfang database were searched. The data for therapeutic efficacy, melasma area and severity score, and incidence rate of adverse reactions were extracted from the included studies.

RESULTS

A total of 20 studies involving 1,182 patients were included in this network meta-analysis. Combined therapy with carbamic acid and 1064-nm picosecond laser was the best measure. Melasma area and severity index score of patients after low-power fractional CO2 laser treatment was higher than that of patients after the treatment with 1064-nm picosecond laser.

CONCLUSION

Aminomethyl cyclic acid combined with 1064-nm picosecond laser may have the highest effective rate after treatment. Low-power fractional CO2 laser provided the lowest melasma area and severity index score after treatment, and the incidence rate of adverse reactions after treatment, was highest when intense pulsed light was used.

A combination treatment of drug-laser-photon for melasma: A retrospective study of clinical cases

BACKGROUND

Combinational therapy such as taking tranexamic acid while using laser treatment has been proved potential efficacy by many experiments. However, there is few research which contains large samples and consistent observations.

OBJECTIVE

We evaluated clinical efficacy and safety of a new systemic treatment of drug-laser-photon therapy.

METHODS

Retrospective and randomized investigator-blinded study of 75 patients with mixed type melasma was analyzed. At each visit, standardized photographs were taken using VISIA. Modified melasma area and severity index (mMASI) scores were marked using photographs by two dermatologists.

RESULTS

The mMASI score decreased significantly from 6.92 to 3.84 after the treatment. The VISIA analyze right cheek data shows: Spots (from 49.67 ± 3.43 to 56.09 ± 3.31), UV spots (from 41.39 ± 24.45 to 44.56 ± 25.86), and Brown spots (from 23.97 ± 17.89 to 28.16 ± 21.28) are statistically increased (p = 0.035, p = 0.018, p = 0.07). All patients feel varying degrees of improvement, about 10.17% felt very much improved, 30.51% felt much improved (51%-75%), 45.76% felt moderately improved (26%-50%), and 13.56% felt little improved (1%-25%).

LIMITATIONS

This study was no control group.

CONCLUSION

The efficacy and safety profile of the combination of drug-laser-photon therapy systemic treatment in melasma patients has been proved. It has potential possibility to become a new, reliable, widely suitable therapy strategy.

Efficacy and Safety of Low Fluence Nd:YAG Laser Treatment in Melasma: A Meta-Analysis and Systematic Review

BACKGROUND

Low-fluence, multisession therapy of Nd:YAG laser has been widely used for treating melasma.

OBJECTIVE

To evaluate the efficacy and safety of low-fluence Nd:YAG laser toning for melasma using a systematic review and meta-analysis.

METHODS

The PubMed, Web of Science, Embase, and Cochrane Library databases were searched till December 2020. A total of 50 studies (1,772 patients) and 66 studies were selected for the evaluation of the efficacy and complications, retrospectively.

RESULTS

The mean Melasma Area and Severity Index/modified Melasma Area and Severity Index scores for laser toning as monotherapy at <4, 4 to <8, 8 to <12, 12 to <24, and ≥24 weeks after treatment compared with that at pretreatment were -0.51, -0.91, -0.97, -0.92, 0.01 SD, whereas those as combination therapy were -1.64, -1.26, -0.94, not available, -1.45 SD, respectively. An increase in light value and a decrease in relative lightness index have remained up to 8 weeks after laser toning. Complications including hypopigmentation/leukoderma, postinflammatory hyperpigmentation, and recurrence were noted. The incidence of hypopigmentation/leukoderma correlated with the number of laser sessions (p = .036).

CONCLUSION

Low-fluence Nd:YAG laser toning as combination therapy has shown better efficacy than monotherapy and the efficacy seems to diminish with time. This study suggests the positive correlation of hypopigmentation/leukoderma with the number of laser sessions.

Understanding Melasma-How Can Pharmacology and Cosmetology Procedures and Prevention Help to Achieve Optimal Treatment Results? A Narrative Review

Melasma is a chronic skin condition that involves the overproduction of melanin in areas exposed to ultraviolet radiation. Melasma treatment is long-term and complicated with recurrence and resistance to treatment. The pathogenesis of melasma is highly complex with multiple pathologies occurring outside of the skin pigment cells. It includes photoaging, excessive melanogenesis, an increased number of mast cells, increased vascularization, and basement membrane damage. In addition, skin lesions related to melasma and their surrounding skin have nearly 300 genes differentially expressed from healthy skin. Traditionally, melasma was treated with topical agents, including hydroquinone, tretinoin, glucocorticosteroids and various formulations; however, the current approach includes the topical application of a variety of substances, chemical peels, laser and light treatments, mesotherapy, microneedling and/or the use of systemic therapy. The treatment plan for patients with melasma begins with the elimination of risk factors, strict protection against ultraviolet radiation, and the topical use of lightening agents. Hyperpigmentation treatment alone can be ineffective unless combined with regenerative methods and photoprotection. In this review, we show that in-depth knowledge associated with proper communication and the establishment of a relationship with the patient help to achieve good adherence and compliance in this long-term, time-consuming and difficult procedure.

Treatment of melasma by a combination of intense pulsed light with advanced optimal pulse technology and human-like collagen repair dressing: A case series study

To observe the efficacy and safety of a combination of intense pulsed light (IPL) with advanced optimal pulse technology (AOPT) and human-like collagen repair dressing in the treatment of melasma. Ten patients with melasma were treated using IPL with AOPT once a month for a total of 8 times, and received the treatment of external human-like collagen repair dressing after each operation. The efficacy was evaluated with the modified Melasma Area Severity Index (mMASI) score and satisfaction score, respectively, before treatment, after each treatment and at 4 months after the end of the whole treatment course. The melasma was significantly lightened in all 10 patients after 8 times of treatments. The mMASI score before treatment was (8.6 ± 3.8) points, which decreased significantly to (5.1 ± 2.7) points after 8 times of treatments, and there was a significant difference in mMASI score between before and after 8 times of treatments (P = .001). The mMASI score was (3.3 ± 2.2) points at 4 months after the end of whole treatment course, and there was no significant difference in mMASI score between after 8 times of treatments and 4 months after the end of whole treatment course (P > .05). The satisfaction score was (7.2 ± 1.4) points after 8 times of treatments and (7.1 ± 1.4) points at 4 months after the end of whole treatment course, there was no significant difference in satisfaction score between after 8 times of treatments and 4 months after the end of whole treatment course (P > .05). A combination of IPL with AOPT and human-like collagen repair dressing can effectively decrease the severity of melasma, and is associated with a higher patient satisfaction score and a lower risk of relapse after discontinuation of treatment.

Single and combined 1064 nm Q-switched Nd: YAG laser therapy in melasma: a meta-analysis

PURPOSE

This article attempted to describe the efficacy and safety of 1064QNYL in combination with other treatments for refractory melasma.

METHODS

Two researchers independently retrieved randomized controlled trials (RCTs) according to inclusion and exclusion criteria. Primary outcome was evaluated with MASI and mMASI scores in control group and experiment group. The secondary outcome was evaluated with MI scores. We calculated 95%CI of standardized mean difference (SMD) and heterogeneity of the included literature by Higgins I² test, and assessed publication bias by Funnel plots, Egger's, and Begg's tests.

RESULTS

A total of 12 articles including 322 subjects were analyzed. Experiment group was treated with 1064QNYL combined with single treatment (e.g., PDL, IPL, RF, TA). Control group was treated with 1064QNYL alone. A greater reduction of Melasma Area and Severity Index (MASI)/modified Melasma Area and Severity Index (mMASI) scores were shown in experiment group than that in control group at the end of the treatment (SMD, -0.37; 95%CI -0.70 to -0.04, p=0.03, I² =33%). The SMD of MI scores further supported this conclusion by -0.32 (95%CI -0.63 to -0.02, P =0.04, I² =27%). As for adverse events (AEs), combined treatment gave rise to more mild burning, stinging, and erythema that resolved spontaneously. Several studies reported focal purpura, punctate leukoderma, hyperpigmentation and hypopigmentation, and so on.

CONCLUSION

Combined 1064QNYL treatment was better than single laser treatment, with the highest short-term benefit and long-term follow-up to maintain the effect in favor of combined treatment.

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.

Treatment of melasma with platelet-rich plasma: a self-controlled clinical trial

BACKGROUND

Melasma is a common circumscribed hypermelanosis of sun-exposed areas of the skin. Platelet-Rich Plasma therapy has been evidenced to inhibit melanin synthesis in animals and humans OBJECTIVE: To determine the effectiveness of platelet-rich plasma as a treatment for melasma.

MATERIALS AND METHODS

Twenty female patient with melasma were involved in this study. The intervention included three Platelet-Rich Plasma application sessions at 15-day intervals. Patients were evaluated before and after treatment. Variables measured included the facial melanin concentration using the Melasma Area and Severity Index score, Melasma Quality of Life Scale satisfaction grade, and histologic changes.

RESULTS

Mean age was 41±7 years. An initial MELASQOL score of 42±14.8 and final score of 16.6±7.2 (p = 0.008) were reported; the initial and final MASI score were 15.5±8.4 and 9.5±7.2 (p = 0.001), respectively. The dermatoscopy examination revealed a decrease in pigmentation after intervention (p=0.001). Histopathologic improvement was detected in reductions in cutaneous atrophy (14 [70%] vs. 11 [55%]), solar elastosis (15 [75%] vs.11 [55%]), and inflammatory infiltrate (9 [45%] vs. 6 [30%]), before and after treatment, respectively.

CONCLUSIONS

The intervention was associated with decreased intensity of the melasma patch and improved skin quality, shown by the MELASQOL and MASI scores. This article is protected by copyright. All rights reserved.

Efficacy of low-fluence 1,064 nm Q-switched Nd: YAG laser for the treatment of melasma:a meta-analysis and systematic review

BACKGROUND

Melasma is considered as a type of acquired facial pigmentary disorder that is challenging to treat. Low-fluence 1,064 nm Q-switched Nd: YAG laser (LQSNY) has clinical benefits against melasma, however there are some disputes.

OBJECTIVE

To explore these contentious views, we conducted a meta-analysis and systematic review to evaluate the efficacy and safety of LQSNY monotherapy and combined therapy for the treatment of melasma.

METHODS

The PubMed, Embase, Cochrane Library, and Web of Science databases were searched for relevant articles from inception to July 2021. The resulting data were analyzed using the Review Manager 5.3 software.

RESULTS

Twelve eligible studies comprising 358 patients were included. No significant differences in melasma area and severity index (MASI) were observed between the LQSNY and drug groups (mean difference (MD):-0.26, 95% confidence interval (CI):-1.16-0.64, P=0.57). We found that combination therapy with LQSNY and drugs had a greater MASI improvement compared to LQSNY therapy alone (MD: 1.78, 95% CI 0.93-2.63, P<0.0001), nevertheless, no statistically significant results were found in melanin index (MI) and self-assessment. The melasma improvement was similar when using LQSNY alone and LQSNY combined with other lasers in terms of RMASI (MD 0.05, 95% CI:-0.61, 0.70, P=0.56). Compared to intense pulsed light (IPL) alone, LQSNY with IPL provided an added benefit for melasma severity (MD:3.23, 95%CI:0.65-5.81, P=0.01).

CONCLUSION

LQSNY can be applied as an alternative treatment for drug intolerance. Combination therapy with LQSNY and drugs or other lasers may have pleasantly surprising efficacy, but numerous studies are still needed to verify this.

Laser therapy in the treatment of melasma: a systematic review and meta-analysis

Melasma is a highly prevalent and cosmetically disfiguring pigmented skin disease. The post-treatment results are often unsatisfactory. A large number of clinical trials have tried to prove the effectiveness of the combination therapy involving laser therapy, but the results have been indeterminate. This study aimed to evaluate the effectiveness of laser treatment for melasma via a systematic review and meta-analysis. We respectively searched 4 databases and clinicaltrials.gov as of June 8, 2021. Two researchers independently searched for literature and extracted data. Study outcomes were computed by weighted mean differences (WMD). All statistical analyses were performed by the Review Manager version 5.3, STATA version 14 software at 95% confidence interval. We obtained 22 eligible studies which involved a total of 694 patients. After the heterogeneity test and sensitivity analysis, we took a subgroup meta-analysis on the before and after treatment of different laser types. We found that most lasers and laser-based combinations were associated with reduced melasma area and severity index (MASI), such as low-fluence Q-switch 1,064-nm Nd: YAG laser (QSNYL) (WMD: - 2.76; 95% CI: - 3.53 to - 1.99), fractional ablative CO2 laser (WMD: - 9.36; 95% CI: - 12.51 to - 6.21), and fractional ablative 2940-nm Er: YAG laser (WMD: - 2,72; 95% CI: - 3.94 to - 1.49). Significant decrease was seen in neither MASI score of non-ablative 1550-nm fractional laser (WMD: - 1.29; 95% CI: - 2.80 to 0.21) and picosecond laser (WMD: - 0.58; 95% CI: - 1.43 to 0.27), nor melanin index (MI) of low-fluence QSNYL treatment (WMD: 10.17; 95% CI: - 4.11 to 24.46). When using laser to treat melasma, various adverse reactions may occur, most of which will resolve quickly without subsequent treatment, such as edema, erythema, scaling, and burning sensation after treatment. However, for patients with darker skin, there are risks of postinflammatory hyperpigmentation and hypopigmentation. The laser and laser-based combination treatment for melasma could significantly reduce the MASI score, which was showed by our systematic review and meta-analysis.

Lasers, lights, and compounds for melasma in aesthetics

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.

The pathogenesis of melasma and implications for treatment

BACKGROUND

Melasma is a complex and poorly understood disorder, with high rates of treatment failure and recurrences.

OBJECTIVES

We aimed to review the current knowledge of the pathogenesis of melasma and apply this knowledge to clinical implications on relevant therapeutic interventions.

METHODS

A systematic PubMed search was performed using the search term "((melasma[Text Word]) OR facial melanosis[Text Word]) AND (pathogenesis OR causality[MeSH Terms])" for articles published between 1990 and 2020. Included articles were then evaluated by two authors and assessed for relevant pathomechanistic pathways, after which they were divided into groups with minimal overlap. We then reviewed current treatment modalities for melasma and divided them according to the involved pathomechanistic pathway.

RESULTS

A total of 309 search results were retrieved among which 76 relevant articles were identified and reviewed. Five main pathomechanisms observed in melasma were identified: (1) melanocyte inappropriate activation; (2) aggregation of melanin and melanosomes in dermis and epidermis; (3a) increased mast cell count and (3b) solar elastosis; (4) altered basement membrane; and (5) increased vascularization. Treatment modalities were then divided based on these five pathways and detailed in 6 relevant tables.

CONCLUSION

The pathophysiology of melasma is multifactorial, resulting in treatment resistance and high recurrence rates. This wide variety of pathomechanisms should ideally be addressed separately in the treatment regimen in order to maximize results.

A review of combined treatments for melasma involving energy-based devices and proposed pathogenesis-oriented combinations

BACKGROUND

Melasma is an acquired disorder of hyperpigmentation, affecting a million individuals worldwide. Energy-based devices (EBDs) employed to treat melasma include various types of lasers, intense pulsed light (IPL), and radiofrequency (RF). Recent studies have attempted to address recalcitrant and recurring melasma by combining energy-based devices with topical or oral medications.

OBJECTIVE

This article reviews EBDs-based augmented treatment for melasma and suggests practical pathogenesis-oriented treatment regimens. Treatment algorithms are proposed to address various components of melasma.

METHODS

A systematic PubMed search was conducted acquiring information from various studies on combination treatments of melasma involving EBDs.

RESULTS

The 286 retrieved articles were filtered by title to contain at least one type of energy-based modality such as laser, IPL, or RF along with at least one other treatment method. Based on their subject matter, combinations were further categorized into the subheadings: laser plus medication, laser plus laser, and IPL- and RF-containing treatment methods.

CONCLUSION

There are many energy-based combination treatments that have been explored for mitigation of melasma including laser therapy with medication, multi-laser therapies, IPL, RF, and microneedling devices. Melasma is an exceedingly difficult condition to treat, however, choosing the appropriate tailor-made treatment combination can improve the final outcome.

The efficacy of energy-based devices combination therapy for melasma

Melasma is a recalcitrant pigmentary disease with a complex pathogenesis. Monotherapy often results in unsatisfactory results with high recurrence rate. In this review article, we evaluate efficacy of energy-based devices combination therapy for melasma. We reviewed published literature since 2010 up to November 2020 regarding adjuvant therapy of energy-based devices with other treatment modalities in the treatment of melasma. After final selection, we assessed 49 articles. Energy-based devices include lasers, non-coherent lights, radiofrequency, iontophoresis, sonophoresis, microneedling, and microdermabrasion. Adjuvant therapies other than energy-based devices were lightening agents, chemical peels, platelet rich plasma (PRP) and mesotherapy. Combination of Q-switched neodymium-doped: yttrium, aluminum, and garnet (QSNY) with either intense pulsed light therapy (IPL) or pulsed-dye laser (PDL) are recommended in recalcitrant melasma in patients with light skin photo types and with dilated skin vessels (especially with PDL). Combination of fractional microneedling radiofrequency or microneedling with QSNY leads to promising results and is a safe treatment modality, especially in darker skin types. Application of topical lightening agents in combination with laser therapy leads to higher efficacy with less adverse effects (post-inflammatory hyperpigmentation) and rebound of melasma. Combination of ablative techniques with QSNY is not recommended, due to the high risk of permanent adverse effects such as guttate hypopigmentation and exacerbation of melasma.

Comparison between the use of intense pulsed light and Q-switched neodymium-doped yttrium aluminum garnet laser for the treatment of axillary hyperpigmentation

BACKGROUND

Axillary hyperpigmentation (AH) is a condition in which axillary skin is darker than the adjacent areas. To date, there is no standard treatment for AH. The Q-switched neodymium-doped yttrium aluminum garnet 1064-nm(QS) laser and intense pulsed light (IPL) are two effective modalities for the treatment of pigmentary disorders; however, the efficacy and safety levels of both treatments for AH have not yet been compared in a controlled study.

AIMS

To evaluate and compare the efficacy and safety of the QS laser and IPL in the treatment of AH.

METHODS

A randomized, split-side study was conducted on 22 subjects; all subjects received a total of five split-side treatments every 2 weeks. The efficacy was determined using the melanin index (MI), color chart level using the Pantone SkinTone™ Guide, improvement grading scale (IGS), and patient satisfaction scores at weeks 2, 4, 6, 8, and 10.

RESULTS

The results showed that there was no significant difference in MI, color chart level, IGS, and patient satisfaction scores between the two treatments. Both treatments significantly improved AH after three sessions. However, the pain score was lower for IPL treatment. The adverse effects were transient and were found after IPL treatment in one participant (4.45%) who developed hyperpigmentation and another participant (4.45%) who developed erythema.

CONCLUSIONS

Intense pulsed light therapy is safe and effective for the treatment of AH, with no significant difference in the outcome compared with QS laser treatment.

Combined isobutylamido thiazolyl resorcinol and low-fluence Q-switched Nd: YAG laser for the treatment of facial hyperpigmentation: A randomized, split-face study

BACKGROUND

Isobutylamido thiazolyl resorcinol (ITR) is a novel anti-tyrosinase recently shown to be effective in the treatment of hyperpigmentation. Low-fluence Q-switched Nd:YAG 1064-nm laser (LFQS) has proven to be effective for various hyperpigmentary conditions. However, there is no study on the efficacy and safety of combined ITR and LFQS treatment.

OBJECTIVES

To compare the efficacy and safety of combined ITR and LFQS with LFQS monotherapy for facial hyperpigmentation.

MATERIALS AND METHODS

Patients with symmetrical facial hyperpigmentation were treated with five sessions of once weekly LFQS on the whole face. One side was randomly treated with ITR and the other side received a placebo cream for 12 weeks. Patients were followed for 8 weeks after the last laser treatment. Relative lightness index (RL*I), Facial Hyperpigmentation Severity Score on the malar area (FHSS_m ), patient satisfaction, recurrence, and adverse events were recorded.

RESULTS

Twenty-four patients completed the study. Both sides demonstrated significant reductions of mean RL*I and mean FHSS_m from baseline (P < .01). At the 4th week, the ITR-treated side showed more improvement of mean RL*I than the placebo-treated side (62.5% vs 47.3% improvement, P < .05). The mean FHSS_m on the ITR-treated was reduced at a significantly higher percentage than the placebo-treated side (54.4% vs 40.2% reduction, P < .05). Partial recurrence was observed on both sides. No serious side effects were noted.

CONCLUSION

Combined ITR and LFQS therapy was more superior than LFQS monotherapy in the treatment of facial hyperpigmentation. ITR may serve as adjuvant for patients with such condition.

A Meta-analysis-Based Assessment of Intense Pulsed Light for Treatment of Melasma

BACKGROUND

A safe and effective treatment for melasma, an acquired refractory pigmented skin disease, remains a problem, although numerous clinical trials have explored the possibility of combined therapy involving intense pulsed light. To date, little is known regarding the efficacy of this treatment. The current study, therefore, sought to explore the effectiveness of intense pulsed light.

METHODS

We used published studies from literature databases, based on established inclusion criteria, to calculate standardized mean differences (SMDs) and risk ratio (RRs), and evaluated the effectiveness of combined therapy with intense pulsed light in melasma patients. We performed data analysis using the Review Manager 5.3 software at 95% confidence interval.

RESULTS

We obtained a total of 8 studies, involving 215 patients, from the databases and found a significant effect on efficacy following combined therapy with intense pulsed light. Specifically, the melasma area and severity index (MASI) score was significantly low (SMD = 0.61, CI [0.42, 0.80] P < 0.0001 for a fixed-effects model), while a four-point scoring scale self-assessment by patients was significantly high (RR = 1.44, CI [1.17, 1.76] P = 0.0004 for a fixed-effects model).

CONCLUSION

Our meta-analysis showed that IPL-based combination therapy for melasma can effectively reduce the MASI score and result in higher satisfaction among patients, indicating an effective method for treatment of the condition.

LEVEL OF EVIDENCE III

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 www.springer.com/00266.

Melasma Treatment: An Evidence-Based Review

BACKGROUND

Melasma is an acquired, chronic pigmentary disorder predominantly affecting women. It may significantly affect quality of life and self-esteem due to its disfiguring appearance. Multiple treatments for melasma are available, with mixed results.

OBJECTIVE

The aim of this article was to conduct an evidence-based review of all available interventions for melasma.

METHODS

A systematic literature search of the PubMed electronic database was performed using the keywords 'melasma' and/or 'chloasma' in the title, through October 2018. The search was then limited to 'randomized controlled trial' and 'controlled clinical trial' in English-language journals. The Cochrane database was also searched for systematic reviews.

RESULTS

The electronic search yielded a total of 212 citations. Overall, 113 studies met the inclusion criteria and were included in this review, with a total of 6897 participants. Interventions included topical agents, chemical peels, laser- and light-based devices, and oral agents. Triple combination cream (hydroquinone, tretinoin, and corticosteroid) remains the most effective treatment for melasma, as well as hydroquinone alone. Chemical peels and laser- and light-based devices have mixed results. Oral tranexamic acid is a promising new treatment for moderate and severe recurrent melasma. Adverse events from all treatments tend to be mild, and mainly consist of skin irritation, dryness, burning, erythema, and post-inflammatory hyperpigmentation.

CONCLUSIONS

Hydroquinone monotherapy and triple combination cream are the most effective and well-studied treatments for melasma, whereas chemical peels and laser- and light-based therapies are equal or inferior to topicals, but offer a higher risk of adverse effects. Oral tranexamic acid may be a safe, systemic adjunctive treatment for melasma, but more studies are needed to determine its long-term safety and efficacy. Limitations of the current evidence are heterogeneity of study design, small sample size, and lack of long-term follow-up, highlighting the need for larger, more rigorous studies in the treatment of this recalcitrant disorder.

Laser and laser compound therapy for melasma: a meta-analysis

Background: Treatment of melasma is challenging because its pathogenesis is unclear and it is prone to recurrence. We performed a meta-analysis to evaluate the efficacy and safety of laser and laser compound therapy for melasma.Methods: We searched the Cochrane, Embase, and Medline databases for all relevant studies published from inception to July 2018. All randomized controlled trials of melasma describing treatment with lasers or laser compound therapy were included.Results: A total of 346 patients were enrolled in nine RCT studies. Laser therapy and laser compound therapy had better PGA (MD: 1.96 (95% CI: 0.17, 3.75); I² = 0%) and mMASI scores (MD: -1.57 (95% CI: -3.08, -0.05); I² = 19%) than drug and laser therapy, respectively. Four studies were assessed to be of low risk of bias. Subgroup analysis was consistent with the results of the meta-analysis, reflecting the reliability of our results.Linking evidence to action: The results of this meta-analysis provide evidence that laser and laser compound therapy can improve the area and severity of melasma. Further high-quality clinical studies should be carried out in the future to confirm this conclusion. Abbreviations: MASI: Melasma Area and Severity Index; mMASI: modified Melasma Area and Severity Index; PGA: patient global assessment; MI: melasma index.

Postinflammatory hyperpigmentation: A comprehensive overview: Epidemiology, pathogenesis, clinical presentation, and noninvasive assessment technique

Postinflammatory hyperpigmentation (PIH) commonly occurs after various endogenous and exogenous stimuli, especially in dark-skinned individuals. PIH is one of the most common complications of procedures performed using laser and other light sources. The severity of PIH is determined by the inherent skin color, degree and depth of inflammation, degree of dermoepidermal junction disruption, inflammatory conditions, and the stability of melanocytes, leading to epidermal and dermal melanin pigment deposition. The depth of melanin pigment is the key factor to predict prognosis and treatment outcome. Epidermal hyperpigmentation fades more rapidly than dermal hyperpigmentation. Various inflammatory disorders can eventually result in PIH. The evaluation of pigmentation using noninvasive tools helps define the level of pigmentation in the skin, pigmentation intensity, and guides therapeutic approaches. This first article in this 2-part series discusses the epidemiology, pathogenesis, etiology, clinical presentation, differential diagnoses, and investigation using noninvasive assessment techniques that objectively determine the details of pigmentation.

A review of laser and light therapy in melasma

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.

Pulsed alexandrite laser for treatment of melasma in Asian patients

BACKGROUND

Melasma is a common acquired facial hypermelanosis with irregular brownish macules and patches. The clinical course is often fluctuated and refractory to treatment. The present study was conducted to evaluate the efficacy and safety of pulsed alexandrite laser for the treatment of melasma.

MATERIALS AND METHODS

In the present study, we enrolled Asian patients with melasma. All the patients received four monthly treatments with a pulsed alexandrite laser. The severity of melasma was evaluated by a blinded dermatologist, using the Modified Melasma Area and Severity Index (MMASI), and by patient assessment, using a visual analogue scale, at baseline, before each treatment, and at the 1-month and 3-month follow-up visits after the last treatment.

RESULTS

Twenty-three patients completed all treatments and follow-up visits. The MMASI scores decreased significantly from 8.71 ± 5.83 at baseline to 6.07 ± 4.65 after four sessions of treatment (P < 0.05) and 6.91 ± 4.97 at 3 months after the last laser treatment (P < 0.05). After 4 sessions of treatment, 10 patients (43.5%) described their improvement as marked and excellent (>60% improvement). The treatments were well tolerated with only mild skin reaction.

CONCLUSION

In the present study, we demonstrated that the pulsed alexandrite laser is safe and effective to treat melasma in Asian skin.

Lasers in Melasma: A Review with Consensus Recommendations by Indian Pigmentary Expert Group

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.

Evidence-based Review, Grade of Recommendation, and Suggested Treatment Recommendations for Melasma

Treatment of melasma is known to be less satisfactory, often incomplete, and relapse is frequent. Although many treatment options are available, they are either known to be unsafe on long-term use or their long-term safety profile is unknown. Patients often use various drugs, even topical steroid-based preparation without any medical supervision for long period of time, making the skin unsuitable for many of the drugs available. Thus, there has been gross disparity among the treating physician about what drugs and what regimen are best suitable for various categories of melasma patients and in different situations. With this background, numerous newer drugs, mostly combinations of some proprietary molecules or even unknown plant extracts, have flooded the market for the management of melasma. Information on efficacy or safety of these products are almost unknown. Studies on Asian people, especially Indian population, are far less commonly available. Therapeutic guideline for use on Indian patients with melasma is almost missing. Extrapolation of data from Caucasian people for use on Asian people may not be scientifically justifiable because Caucasian and Asian people are known to have inherent difference in their response as well as tolerance to the drugs used for melasma. With this background, we have extensively evaluated, following a strict, scientifically designed protocol, all the available studies on melasma management till May 2016 and prepared this document on level of evidence, grade of recommendation and suggested therapeutic guideline for melasma as per the method proposed by Oxford Centre of Evidence-Based Medicine. Various ethical, social, logical, regional, and economic issues in the context of Indian and similar populations were given due importance while preparing the suggested therapeutic recommendation.