If you’re a dermatologist, you’ve undoubtedly treated patients with melasma. They’re most probably women, somewhere in their twenties to forties, with skin that has even the slightest ability to tan. They very well might be on birth control pills or have recently given birth. The darker brown pigment that appears symmetrically on their cheekbones, on the upper lip, the bridge of the nose, on the center of the forehead and across the temples leads you towards a diagnosis. You rarely notice the patches below the jawline, or on the tip of the nose.
Melasma isn’t totally understood, but you know that sun exposure (UVA as well as visible light), pregnancy, contraceptive and even menopause-related hormonal changes can trigger the melanocytes to produce excessive pigment in the areas of melasma. The condition also can run in the family. Although melasma can’t be cured, it can be mitigated with proper treatment combined with protective measures.
Treating with topicals
You explain to your patient what she must do to avoid the triggers that can exacerbate her melasma, such as being vigilant about sun exposure. “Many patients with a little melasma on their cheekbones told me it spread after they travelled to Mexico or Florida for a week,” said Dr. Amit Pandya, a dermatology professor at the University of Texas Southwestern and an expert in pigmentation research. His protective recommendations include using makeup with at least 3 percent iron oxide to block visible light and sunscreen to block the UV light, doing outdoor activities before 9 am or after 5 pm, wearing a hat, keeping the visor down in the car and closing the blinds on office and home windows to keep the sun away from the face.
His protective recommendations include:
- Using makeup with at least 3 percent iron oxide to block visible light and sunscreen to block the UV light
- Doing outdoor activities before 9 am or after 5 pm
- Wearing a hat
- Keeping the visor down in the car
- Closing the blinds on office and home windows to keep the sun away from the face
You also prescribe topicals, starting with a tyrosinase inhibitor such as kojic acid or hydroquinone cream to prevent your patients’ melanocytes from using the enzyme tyrosinase to produce melanin. And, you’ll often combine the topical with a treatment that will gently remove the superficial layers of the skin, such as a chemical peel, alpha hydroxy acid, or Retina-A,
which helps the hydroquinone to penetrate deeper.
Unfortunately, you’ve seen too many patients who had aggressive chemical peels at spas, but did not use tyrosinase inhibitors. The peels introduced inflammation, redness or irritation of the skin and actually made their melasma even darker. Since the melasma pigment may go all the way down to the bottom of the epidermis, a harsh chemical peel that removes only the top layers will not improve the condition in patients with darker skin and really dark melasma. Prescribing a tyrosinase inhibitor is essential in these cases.
Laser focused in Melasma
Melasma may disappear after a woman gives birth or stops taking birth control pills, but it can plague many women for decades. By now you’ve treated enough patients to know that topicals don’t work on every melasma patient, and it’s distressing to have a woman return to your office over and over again without seeing significant results.
“Topicals do help, but not as much as the laser,” said Dr. David J. Goldberg, a prominent dermatologist with practices in New York and New Jersey who is recognized for his exceptional techniques with aesthetic light and laser equipment. “By the time someone comes to see me she’s tried topical creams, but they didn’t work. The majority of melasma patients who didn’t benefit from topicals will respond to lasers,” Dr. Goldberg said. “I think of lasers as the cake and topical creams as the icing.”
Faster Treatment Time with the PiQo4
Dr. Goldberg’s laser of choice for melasma is the PiQo4 from Lumenis. Featuring four wavelengths (1064nm, 532nm, 650nm, and 585nm), the PiQo4™ system is “sensational for removing tattoos in all colors and for deep pigmentation such as melasma,” said Dr. Goldberg, who was one of the first to use the Lumenis PiQo4 machine in the United States. It also treats other pigmented lesions such as nevi, lentigines, cafe-au-lait birthmarks and seborrheic keratosis.
Delivering triple the peak power of older lasers, PiQo4 lets doctors work with a 15mm versus a 2 to 4 mm spot size, which speeds up treatment time significantly. An average tattoo can be treated in 30 seconds or less, and an entire face can be treated for pigmentation or skin texture improvement in 15 minutes. What’s more, the 1064nm wavelength and picosecond laser pulses are safe and effective on olive or darker skin types, whereas 755nm systems are limited to lighter skin types. Having four wavelengths provides a greater ability to couple the type and depth of pigmentation with an appropriate wavelength.
Treating Melasma’S Vascular Component
Dr. Goldberg also has learned a great deal about the vascular component of melasma over the years, he noted that “Sometimes we actually can see the blood vessels, sometimes not, but they’re always present because melasma is an inflammatory skin condition, and, increased blood vessels actually make melasma worse. We typically use a 1064nm laser to work on the melasma pigment, but nothing was available for the vascular aspect. It seemed logical that we’d get better overall results if we could decrease the underlying inflammation in addition to the melasma pigment.” The introduction of PiQo4 gave Dr. Goldberg the chance to put his theory to the test, using a combination of the 1064nm and 585nm laser, because the 585nm laser could also be used on blood vessels.
Embarking on the first study that would look at treating melasma pigment and vascular issues, Dr. Goldberg’s 17 female subjects, ranging from 30 to 55 years old, each receiving three PiQo4 sessions. Only the pigment was treated on one side of their face, while the pigment and the vascular components were treated on the other side. Although Dr. Goldberg also recommends sunscreens and bleaching creams in addition to the laser when treating melasma, he didn’t use topical treatments in his study “because we wanted to see what the laser alone would do,” he explained.
“Lo and behold, while the pigment side was improved, it was never improved as well as on the other side, where we addressed the pigment and vascular issues at the same time,” Dr. Goldberg happily reported.
PiQo4 is FDA-cleared for the removal of benign pigmented lesions like melasma, tattoo removal and skin resurfacing. And while there may not be a cure for melasma yet, based on the promising results of Dr. Goldberg’s ground-breaking study, the PiQo4 is an exciting new option for effectively and safely treating melasma for patients of all skin types.
1 Source: dermalinstitute.com
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