Intense Pulsed Light for the Treatment of Refractory Melasma in Asian Persons

Definition of refractory melasma and its treatment: a review

Although patients with refractory melasma have been treated using various methods, there is still no precise definition or summary of the therapies. To define refractory melasma and conduct a review of the treatments, we searched for relevant publications in PubMed, Web of Science, and the Cochrane Library, and a total of 35 references were obtained. Refractory melasma can be roughly defined as an ineffective treatment for melasma, including topical bleaching agents, chemical peels, laser therapy, microdermabrasion for more than six months, or chemical peels treated more than six times. Meanwhile, physicians should be careful when treating patients with darker skin and dermal or mixed types of melasma since these individuals do not respond well to treatment. Lasers combined with other methods, especially different types of lasers or topical agents, are considered more effective than monotherapy. Oral tranexamic acid (TXA) is a prospective cure for refractory melasma. Other methods include a combination of chemical peels, microneedling, or injections with additional therapies. In conclusion, we were able to provide a rough definition of refractory melasma and list the available therapies. According to the literature, the most prevalent treatment is laser combination therapy. However, laser treatment should be considered only after topical agents and chemical peeling have failed. Considering its side effects, efficacy, and safety, oral TXA may be a better option, but more research is needed to make a firm conclusion. Moreover, maintenance therapy is required after treatment.

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

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.

Effectiveness of combination therapy of broadband light and intradermal injection of tranexamic acid in the treatment of chloasma

OBJECTIVE

To investigate the efficacy and safety of broadband light (BBL) combined with intradermal injection of tranexamic acid for treating melasma.

METHODS

120 women with melasma admitted to our hospital from January 2021 to April 2022 were randomly categorized into the following groups: control group, treated with 250 mg tranexamic acid given orally twice daily, except during menstruation; group I, treated with BBL (Sciton, Inc., USA) monthly; group II, received intradermal injections of tranexamic acid monthly; and group III, treated with BBL with intradermal injection of tranexamic acid monthly. Treatment in each group lasted three months. The MASI (Melasma Area Severity Index) and VISIA (Canfield VISIA Complexion Analysis) were used for evaluation.

RESULTS

After treatment course, MASI scores and VISIA brown spot and red zone ranking improved in all four groups (p < 0.05). The decrease in MASI scores and improvement rates of VISIA brown spot and red zone rankings were not significantly different among the control group, group I, and group II; however, the decreased MASI scores and improvement rates of VISIA brown spot and red zone rankings were significantly higher in group III than in the other three groups (p < 0.05).

CONCLUSION

The effect of BBL combined with the intradermal injection of TA in the treatment of melasma is remarkable. This combination therapy can be an alternative and effective treatment for managing melasma.

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.

Evaluation of Efficacy and Safety Profile of Intense Pulsed Light Treatment in Melasma in Darker Skin Type

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.

Low-fluenced erbium:yttrium-aluminium-garnet laser treatment in combination with broadband light pretreatment for various pigmentation disorders in Asian patients

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.

Combination of Hydroquinone and Fractional CO2 Laser versus Hydroquinone Monotherapy in Melasma Treatment: A Randomized, Single-blinded, Split-face Clinical Trial

Background:

Melasma is a chronic hyperpigmentation skin disorder mainly affecting women in the reproductive age. Available treatments for melasma do not lead to long-term satisfactory results.

Aims:

This study aimed to compare the efficacy of fractional CO₂ laser in combination with topical therapy to topical therapy alone.

Materials and Methods:

Forty women with bilateral melasma were studied in this randomized single-blinded clinical trial. Each side of the face was randomly allotted to either topical hydroquinone 4% or combination of topical hydroquinone 4% and fractional CO₂ laser. Patients received three sessions of laser therapy at 3-week intervals. Hydroquinone 4% application on both sides maintained for 3 months after the last laser session. The clinical improvement (darkness [D] and homogeneity [H] of hyperpigmentation) was measured by a blinded main investigator and an outcome assessor. Furthermore, improvement was assessed by physician's global assessment (PGA) and patient satisfaction (visual analog scale [VAS] score).

Results:

Significant reduction in D observed 3 weeks after combination therapy (P<0.001) and 6 weeks after monotherapy (P<0.001). Reduction in H became significant after 6 weeks in both groups (P<0.001). However, the two methods were not considerably different in any session (P>0.05). Furthermore, control and experiment sides were not significantly different considering VAS score and PGA (P>0.05).

Conclusion:

Considering the short-term outcome of laser and hydroquinone therapy, we can apply it to obtain earlier positive results. However, because of the lack of significant difference between the two methods and also the high cost of laser therapy, it seems better not to recommend fractional CO₂ laser to patients as adjunctive therapy for long-term treatment of melasma.

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.

Updates in the understanding and treatments of skin & hair disorders in women of color

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).

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.

Objective assessment of intensive targeted treatment for solar lentigines using intense pulsed light with wavelengths between 500 and 635 nm

Background and Objectives

Solar lentigines are commonly found in sun‐exposed areas of the body including hands, neck, or face. This study evaluates the efficacy of an intense pulsed light (IPL) device, with wavelengths between 500 and 635 nm and delivered with a targeted tip, for the treatment of solar lentigines on Japanese skin.

Study Design/Materials and Methods

Forty Japanese patients with solar lentigines received one IPL treatment with a targeted treatment tip that emits wavelengths between 500 and 635 nm and contact cooling. Pulses were delivered through a targeted tip to each lentigo until mild swelling and a gray color were observed. Digital photographs and gray level histogram values were taken pre‐ and post‐treatment, and patient assessments were recorded post‐treatment.

Results

Significant improvement was observed for all patients in digital photographs and mean values of gray level histograms (P < 0.0001). Ninety percent of patients reported satisfaction with the improvement of the treatment area and convenience of the procedure. Complications were minor and transitory, consisting of a slight burning sensation and mild erythema which resolved within 5 hours of treatment. No serious adverse events were observed.

Conclusions

A short‐wavelength IPL, delivered with a targeted tip and contact cooling, offers a highly efficacious treatment for solar lentigines in Japanese skin with minimal downtime and complications. Lasers Surg. Med. 48:30–35, 2016. © 2015 The Authors. Lasers in Surgery and Medicine Published by Wiley Periodicals, Inc.

Updates in the understanding and treatments of skin & hair disorders in women of color

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).

Evidence-based treatment for melasma: expert opinion and a review

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.

Treatment of refractory melasma with combination of topical 5% magnesium ascorbyl phosphate and fluorescent pulsed light in Asian patients

BACKGROUND

Melasma is an acquired disorder of hypermelanosis of great psychosocial concern. The treatments with various conventional therapies are often unsatisfactory. Lasers and light sources have been used to treat pigmented lesions, but in Asian skin with higher melanin content, such treatments may be challenging.

OBJECTIVES

To determine the effectiveness of treating melasma with a combination of topical 5% magnesium ascorbyl phosphate (MAP) and fluorescent pulsed light (FPL).

MATERIALS AND METHODS

Patients of skin types III-V with refractory melasma were treated for 12 weeks with topical application of 5% MAP and three sessions of FPL (570-950 nm) at 3, 6, and 9 weeks (fluence 12-14 J/cm(2) , pulse width 15 ms, and spot size 3 cm(2) ). They were followed up for another 12 weeks to assess the persistence of treatment benefit. Digital photographs of the patients were taken at each visit. Treatment efficacy was determined by calculating mean melasma area and severity index (MASI) at the beginning and then at weeks 6, 12, and 24. The subjective assessment was done by comparing pre-treatment and post-treatment photographs by an independent observer and self-assessment by patients using four-point scoring scale (1, poor, 2, fair, 3, good, and 4, excellent).

RESULTS

Sixty-five patients completed the study. The baseline mean MASI score of 14.80 decreased to 4.53 at the 12th week (end of treatment) and 6.35 at the 24th week (end of follow-up). The overall regression of mean MASI at these end-points was 69.3% and 57% (P < 0.01). The pre- and post-treatment photographic evaluation by independent observer and patients' self-assessment at the 12th week showed good to excellent response (scores 3 and 4) in 52.3% and 44.6% cases, respectively. No significant adverse effects of treatment were noted.

CONCLUSION

Combination of 5% MAP with FPL is effective, well tolerated, and safe in treating refractory melasma in Asian patients but for persistent improvement, maintenance treatments would be required.

The aesthetic applications of intense pulsed light using the Lumenis M-22 device

BACKGROUND

Fifteen years have passed since the first Intense Pulsed Light (IPL) devices were introduced into the market. A variety of devices that use light energy for aesthetic puposes are currently manufactured by several companies, and newer devices offering improved performance and features are periodically being introduced. Herein we present our experience with the MP-22 device (Lumenis Ltd., Yokneam, Israel) for cosmetic treatment of benign skin lesions.

PATIENTS AND METHODS

We collected patient data from all patients who received IPL and Nd:Yag laser treatments with the MP-22 over a one year period (Jan 2009-Jan 2010). The study group included 92 patients who were treated on the face, neck, trunk and hands. The main indications for treatment were lentigo and superficial vascular lesions. Patient age ranged from 16 to 72 years old, and 89 patients were female. Exclusion criteria for treatment were suspicion of skin cancer, isotretinoin treatment during the previous 6 months, and pregnancy. Satisfaction after treatment was evaluated by the patients on a scale ranging from 0 to 5, with 5 = excellent, 4 = very good, 3= good, 2= moderate improvement, 1= mild improvement and 0= no improvement.

RESULTS

Ninety-three percent of the patients were satisfied (rating 3, 4 or 5 on the above scale). Ninety-five percent of the patients had one or two treatment sessions. Of the treatments, 82 were on the face, two on the neck, four on the trunk and 13 on the dorsal aspect of the hands. Minor side effects such as erythema for longer than 24 hours and facial edema for more than one day were reported by 9 patients. Major complications such as scars, hyperpigmentation or hypopigmentation were not recorded. The fluence delivered varied from 14-18 J/cm(2).

CONCLUSION

IPL is an effective and safe method for skin treatments, namely removal of vascular and pigmented lesions.

Treatment of melasma with topical agents, peels and lasers: an evidence-based review

BACKGROUND

Melasma is an acquired disorder of hyperpigmentation occurring on the face and predominantly affecting women of childbearing age. It is a chronic, often relapsing condition with a negative impact on quality of life. Current treatments for melasma are unsatisfactory.

OBJECTIVE

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

METHODS

A systematic literature search was performed using PubMed and the keywords 'melasma' or 'chloasma' in the title. The search was further refined by using a filter for 'controlled clinical trials' and 'randomized controlled trial'. The included studies were used to develop recommendations for treatment.

RESULTS

The electronic search yielded a total of 80 citations. Forty studies were included in this review, which had a total of 2,912 participants. Three different therapeutic modalities were investigated-topical agents, chemical peels, and laser and light therapies. Topical depigmenting agents were found to be the most effective in treating moderate-to-severe melasma, with combination therapies, such as triple-combination therapy (hydroquinone, tretinoin, and fluocinolone acetonide), yielding the best results. Chemical peels as well as laser and light therapies were found to have moderate benefit but more studies are needed to determine their efficacy and long-term safety. Adverse events associated with treatment were mild and short-lasting and included skin irritation, dryness, burning, and erythema. The data could not be statistically pooled because of the heterogeneity of treatments and lack of consistency across study designs.

CONCLUSIONS

Topical combination therapies were found to be more effective than monotherapy. Triple combination therapy was found to be the most effective, but approximately 40 % of patients develop erythema and peeling. Chemical peels and laser and light therapies produced mixed results, with increased risk of irritation and subsequent hyperpigmentation, particularly in darker-skinned individuals. Hence, current treatments available for melasma remain unsatisfactory. Many of the studies lacked long-term follow-up. Limitations of current literature include the heterogeneity of study designs, small sample sizes, and poor follow-up rates. Additional evidence for the effects and role of sunscreens is needed. Categorization or stratification of demographic data should also be included in future studies, such as age, melasma type, and duration of melasma prior to initiation of treatment. Patient's perception of improvement versus investigator's assessment of improvement should also be included in future studies and standardized methods of study design and assessment of outcomes are needed to form definitive conclusions on the efficacy of different treatment modalities.

Lasers

Lasers are a very effective approach for treating many hyperpigmented lesions. They are the gold standard treatment for actinic lentigos and dermal hypermelanocytosis, such as Ota nevus. Becker nevus, hyperpigmented mosaicisms, and lentigines can also be successfully treated with lasers, but they could be less effective and relapses can be observed. However, lasers cannot be proposed for all types of hyperpigmentation. Thus, freckles and café-au-lait macules should not be treated as the relapses are nearly constant. Due to its complex pathophysiology, melasma has a special place in hyperpigmented dermatoses. Q-switched lasers (using standard parameters or low fluency) should not be used because of consistent relapses and the high risk of post-inflammatory hyperpigmentation. Paradoxically, targeting the vascular component of the melasma lesion with lasers could have a beneficial effect. However, these results have yet to be confirmed. In all cases, a precise diagnosis of the type of hyperpigmentation is mandatory before any laser treatment, and the limits and the potential side effects of the treatment must be clearly explained to patients.

Lasers for treatment of melasma and post-inflammatory hyperpigmentation

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.

Treatment of melasma with oral administration of tranexamic acid

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.

Intense Pulsed Light and Low-Fluence Q-Switched Nd:YAG Laser Treatment in Melasma Patients

Background

Recently, low fluence collimated Q-switched (QS) Nd:YAG laser has drawn attention for the treatment of melasma. However, it needs a lot of treatment sessions for the substantial results and repetitive laser exposures may end up with unwanted depigmentation.

Objective

We evaluated the clinical effects and safety of the combinational treatment, using intense pulsed light (IPL) and low fluence QS Nd:YAG laser.

Methods

Retrospective case series of 20 female patients, with mixed type melasma, were analyzed using medical records. They were treated with IPL one time, and 4 times of weekly successive low fluence Nd:YAG laser treatments. At each visit, digital photographs were taken under the same condition. Melanin index (MI) and erythema index (EI) were measured on the highest point on the cheekbones. Modified melasma area and severity index (MASI) scores were calculated by two investigators using digital photographs.

Results

The mean values of MI and EI decreased significantly after treatments. The modified MASI score has decreased by 59.35%, on average. Sixty percents of the participants did not require any more treatments, and no clinical aggravations were observed during the follow-up period (mean 5.9 months).

Conclusion

IPL and low fluence laser may elicit a clinical resolution in the mixed type melasma with long term benefits.

Low Fluence Q-Switched Nd: YAG Laser Toning and Q-Switched Ruby Laser in the Treatment of Melasma:A Comparative Split-Face Ultrastructural Study

BACKGROUND

Melasma still presents as a difficult entity to treat, especially in the Asian skin phe-notype. Recently laser toning with the Q-switched Nd:YAG has attracted attention. The present study investigated the efficacy of Q-switched Nd:YAG laser toning for melasma, with a histopathological comparison with the Q-switched ruby laser.

SUBJECTS AND METHODS

Eight Japanese females (41-57 yr, mean 52.5 yr) with Fitzpatrick skin type III and bilateral melasma participated in the study. One half of each subject's face (randomly chosen) was treated with Q-switched 1064 nm Nd:YAG laser toning (pulse width 5-20 ns; spot size, 6 mm diameter; fluence, 3.0 J/cm(2), 5-7 passes, once/week, 4 weeks: QS:YAG group), and the contralateral half with a single treatment using a Q-switched ruby laser (694.5 nm, pulse width 20 ns, spot size 4 mm diameter; fluence 4.0 J/cm2, 1 pass with approximately 20% overlap: QS:Ruby group). Skin biopsies were taken immediately after the 4(th) Nd:YAG session and the single ruby session, and histopathological comparison was performed with light- and transmission electron microscopy (TEM).

RESULTS

Improvement in melasma pigmentation was seen in both the QS:YAG- and QS:Ruby-treat-ed sides, and this was well-maintained in the QS:YAG group. Ultrastructurally, melanin granules were destroyed in both groups, but there was considerably more morphological epidermal and dermal damage in the QS:Ruby specimens compared with minimal epidermal disruption and cellular damage in the QS:YAG specimens.

CONCLUSIONS

Q-switched 1064 nm Nd:YAG laser toning offered superior results in the treatment of melasma in the Japanese skin type compared with the Q-switched ruby laser, both ultrastructurally with less immediately post-treatment cellular damage and macroscopically, and a longer recurrence-free interval.

Treatment of hyperpigmentation

Disorders of hyperpigmentation encompass a plethora of pigmentary problems that can range from inherited to acquired. This article focuses on two prevalent disorders of hyperpigmentation and their treatment: melasma and postinflammatory hyperpigmentation. Each represents an acquired disorder of dyspigmentation with multifactorial etiology, which preferentially affects darker phototypes. Treatment can require a combination of medical, surgical, and laser modalities, as well as patience by both physician and patient. Treatment is limited mainly by the skin phototype of the patient, as darker skin types are more susceptible to adverse effects of treatment.

[Pigmentary lasers]

The pigmentary disorders are a very heterogeneous group with a high therapeutic demand from the patients. The lasers have provided a major advance in the treatment of some pigmentary lesions. The indication and the optimal parameters are actually quite well defined. However, pigmentary lasers have limits and some dermatosis can even be worsened after laser treatment. Those limitations as well as the potential side effects have to clearly be explained to the patients that often seek for a miracle cure.

Pigmentary disorders

A large number of pigmentary disorders exist and although not all dermatologic entities are covered in this article, some of the pigmentary disorders that an internist or general practitioner is likely to encounter are reviewed. The clinician must be able to recognize pigmentary changes that suggest a serious underlying disease. In a situation where a malignancy or other serious illness may exist, an extensive evaluation to detect the disorder is required. This approach can allow for early treatment and referral to an appropriate specialist if necessary. The clinician must also recognize that pigmentary disorders that are essentially cosmetic still cause concern for the patient and can be emotionally distressing. These patients need emotional support and in some cases referral to a mental health specialist.

The safety of hydroquinone: A dermatologist's response to the 2006 Federal Register

Recently, the US Food and Drug Administration proposed a ban on over-the-counter hydroquinone mainly on the basis of high absorption, reports of exogenous ochronosis in humans, and murine hepatic adenomas, renal adenomas, and leukemia with large doses over extended time periods. Systemic exposure to hydroquinone from routine topical application is no greater than that from quantities present in common foods. While murine hepatic adenomas increased, murine hepatocellular carcinomas decreased, suggesting a protective effect. Renal tumors are sex, species, and age specific and therefore do not appear relevant to humans after decades of widespread use. Murine leukemia has not been reproducible and would not be expected from small topical doses. Finally, a literature review of exogenous ochronosis and clinical studies employing hydroquinone (involving over 10,000 exposures under careful clinical supervision) reveal an incidence of exogenous ochronosis in the United States of 22 cases in more than 50 years. Therefore, the proposed ban appears to be unnecessarily extreme.

New and experimental treatments of cloasma and other hypermelanoses

In clinical practice, acquired hyperpigmentations represent the most common disorders of pigmentation the dermatologist has to treat. Despite the large number of depigmenting agents available, the treatment of hyperpigmentations is often unsuccessful and disappointing and is still a challenge for dermatologists. This article focuses on the chemical compounds reported to be in depigmenting or skin lightening agents, their proposed mechanism of action, and their clinical efficacy in the treatment of melasma and hypermelanoses, mainly based on randomized clinical trials. It also reviews chemical peels and their indications, together with the possible uses of laser and intense pulsed light.

Diagnosis and Treatment of Pigmentary Disorders in Asian Skin

Individuals of Asian heritage are predisposed to congenital and acquired pigmentary disorders. Cosmetic enhancement is frequently the primary treatment goal for these benign lesions. Accurate diagnosis of the nature of the pigmentary disorder is fundamental for administering safe and effective therapy. Before the advent of modern laser technology, such reported treatments as cryotherapy, dermabrasion, chemical peeling, and surgical excision resulted in unpredictable results. This article focuses on the diagnosis of disorders of pigmentation in Asian patients and reviews laser and light treatment modalities.

The treatment of melasma: A review of clinical trials

Melasma is an irregular brown or grayish-brown facial hypermelanosis, often affecting women, especially those living in areas of intense UV radiation. The precise cause of melasma remains unknown; however, there are many possible contributing factors. Because of its dermal component and tendency to relapse, melasma is often difficult to treat. The use of broad-spectrum (UVA + UVB) sunscreen is important, as is topical hydroquinone, the most common treatment for melasma. Other lightening agents include retinoic acid (tretinoin) and azelaic acid. Combination therapies such as hydroquinone, tretinoin, and corticosteroids have been used in the treatment of melasma, and are thought to increase efficacy as compared with monotherapy. Kojic acid, isopropylcatechol, N-acetyl-4-cysteaminylphenol, and flavonoid extracts are other compounds that have been investigated for their ability to produce hypopigmentation, but their efficacy, safety, or trial design indicates that the interventions would need further study before they could be recommended. Chemical peels, laser treatments, and intense pulsed light therapy are additional therapeutic modalities that have been used to treat melasma.

Photorejuvenation by Intense Pulsed Light with Objective Measurement of Skin Color in Japanese Patients

BACKGROUND AND OBJECTIVES

This study had two objectives: subjective evaluation of overall skin rejuvenation effects of relatively short-wavelength intense pulsed light (IPL) and objective changes in basic skin tone as measured by a spectrophotometer.

STUDY DESIGN/MATERIALS AND METHODS

Twenty-five women selected at random received a series of three IPL treatments. Efficacy was evaluated over a 3-month follow-up period. Concurrently, a spectrophotometer was used to measure "lightness" (L(*)) to quantify the lightening effect changes to pretreatment and posttreatment basic skin tone.

RESULTS

Subjective improvement of 50% or more was seen in 18 of 25 patients for pigmentation. One patient showed exacerbation of latent epidermal melasma as a complication. In the spectrophotometric analysis, the mean value of L(*) increased from a baseline value of 60.86 to 63.22, at 3-month follow-up period, with statistical significance.

CONCLUSION

IPL skin rejuvenation using relatively shorter wavelengths and pulse widths brought about significant macroscopic and quantitative improvements, especially in the treatment of epidermal pigmentation and improvement of basic skin tone.

A comparison of Q-switched alexandrite laser and intense pulsed light for the treatment of freckles and lentigines in Asian persons: A randomized, physician-blinded, split-face comparative trial

BACKGROUND

Q-switched (QS) pigmented lasers and intense pulsed light (IPL) successfully treat pigment disorders.

OBJECTIVE

We sought to compare efficacy and side effects of QS alexandrite laser (QSAL) and IPL for freckle and lentigo treatment in Asians.

METHODS

In all, 15 patients with freckles and 17 patients with lentigines were treated randomly with one session QSAL in one cheek and two sessions IPL in the other cheek at 4-week intervals. Efficacy was determined using a new pigmentation area and severity index score.

RESULTS

All patients experienced improvement (P < .0001). Postinflammatory hyperpigmentation developed in one patient with freckles and 8 patients with lentigines after QSAL. No postinflammatory hyperpigmentation occurred after IPL. Freckles achieved greater improvement after QSAL than IPL (P = .04). In lentigines, the results after IPL were better than QSAL among those with postinflammatory hyperpigmentation after QSAL.

LIMITATIONS

Limitations include a small case number and short follow-up period.

CONCLUSION

QSAL was superior to IPL for freckle treatment. IPL should be used for lentigines in Asian persons.