Key Points

Role of lasers in treating melasmas
Patient selection
Risk of recurrence, post-inflammatory hyperpigmentation

Dr. Kaufman

Melasma is an acquired condition characterized by hyperpigmented patches, traditionally located on the face. What the classic definition fails to mention is its chronic relapsing nature and its associated therapeutic dilemma.

Dr. Woolery-Lloyd

There are three clinical types of melasma: centrofacial, malar and mandibular. The clinical type does not seem to alter the treatment choices.

There are also four types of melasma based on the location of the melanosomes in the skin, and, hence, described by their woods light pattern. They are: epidermal (accentuated by Woods light), dermal (not accentuated by Woods light), mixed and indeterminate.

Melasma typically occurs in women, with men comprising only 10 percent of all cases. The precise etiology of melasma is not known; however, it has been associated with several other conditions. The most common association is pregnancy and oral contraceptives. Other possible inciting agents include excessive sun exposure, other endocrine abnormalities such as thyroid disease, or ovarian dysfunction. Genetic influences are also likely to contribute, though specific gene identification has not been done.

Cosmetics, heat exposure, phototoxic drugs and anti-seizure medications have also been implicated in this disease.

Melasma associated with an inciting factor, such as oral contraceptives, may resolve once this inciting factor is removed. In many cases, however, this is not the case, and the pigmentation persists.

Therapeutic options for melasma have classically centered on resolving the hyperpigmentation. These have included topical retinoids, hydroquinone, kojic acid and glycolic acid, to name a few.

More recent attention has been focused on prevention of melanosome transfer with agents including soy and niacinamide. Sun protection is an essential component of any therapeutic regimen when treating patients with melasma.

Though readily available, topical therapies often fail to resolve the hyperpigmentation, which relapses when therapy is discontinued.

The search for alternative forms of treatment has led to a recent focus on laser and light devices.

Melasma is certainly more than merely a disorder of hyperpigmentation. In many cases, there is a vascular component to the lesions that generally gets left untreated. The focus of melasma treatment has been predominantly on the pigmentary aspect of the disease, essentially ignoring the other factors.

Lasers may end up playing a role in the therapy of the vascular components of melasma, as this component is nearly impossible to treat with topical agents.

Role of lasers

Do lasers play a role in the treatment of melasma? There are many reports of the use of lasers for melasma, yet no well-controlled, randomized, blinded trials. There are even approvals for treatment of melasma with lasers. However, the answer to this question is definitely still up for debate.

Lasers were first described as a therapy for melasma in 1993. Early laser choices used those wavelengths highly absorbed by melanin. There have been many case reports of successful treatment with these light devices.

The Q-switched lasers have all been tried on melasma, including in combination with other lasers. The majority of reports have shown very high rates of postinflammatory hyperpigmentation (PIH); in some studies, as high as 100 percent.

That being said, many of the cases of PIH were amenable to topical bleaching agents and glycolic acid peels, resulting in an overall improvement of the melasma.

In these reports, it is difficult to ascertain whether the improvement is actually a result of the laser, or of the peels.

Either way, most would agree that the treatment of melasma with traditional Q-switched lasers, including the ruby, alexandrite or the Nd:YAG is risky.

Resurfacing

Traditional resurfacing lasers have also been tried on patients with melasma. Both the Er:YAG and CO2 lasers are associated with almost universal hyperpigmentation in this population and should not be relied upon as a therapeutic option (Mandloto, Alster; Derm Surg. 1999.)

The newer fractional resurfacing lasers so far have shown the most promise for melasma patients. They are not, however, without their shortcomings.

In 2005, the nonablative 1,550 nm fractional resurfacing laser (Fraxel Re:store; Reliant) received a specific approval for treatment of melasma. This approval was based on two separate studies of 20 total patients.

These studies, though promising, are the largest ones to date, clearly demonstrating our lack of research into this topic.

That being said, fractional nonablative resurfacing does improve melasma in many cases. In other cases, it may worsen melasma.

Patients should be treated with hydroquinone to prevent postinflammatory hyperpigmentation. In addition, density settings should be very low. Higher densities result in higher rates of postinflammatory hyperpigmentation.

In addition, treatment sessions should be placed at least one month apart. PIH can occur up to six weeks after treatment, and careful monitoring for this, prior to retreatment, is essential.

Nonablative fractional resurfacing

Refractory cases of melasma can be amenable to nonablative fractional resurfacing.

Nonablative fractional resurfacing results in a laser-induced transport of dermal constituents through the epidermis.

In vivo studies post-nonablative fractional resurfacing indicate that this is the mechanism of action with dermal melasma (Goldberg et al., 2008.)

Nonablative fractional resurfacing could be considered a first-line therapy for dermal melasma in select patients. In other classes of melasma, it is clearly second-tier.

Post treatment worsening of melasma and/or postinflammatory hyperpigmentation are possible. Intervals between treatments must be longer than with non-melasma patients.

In addition, lower fluences and lower densities are typically used. Most patients are pretreated with hydroquinones and strict sun protection with a physical sunblock.

Intense pulsed light

Intense pulsed light devices are also used in the treatment of melasma. Though many patients experience improvement, relapse and PIH occur frequently.

Devices that may show promise for the treatment of melasma, but still with no published data to date, include the light-emitting diodes (Omnilux, Photo Therapeutics), the Spectra VRM dual-pulse laser (Lutronic), and the Laser Genesis (Cutera).

Treatment protocol

So where do laser and light devices fit into the treatment protocol for melasma? In most cases, they are still second line. Only in select cases of dermal melasma could the fractional devices be considered first line, though topical therapy is usually instituted prior to prevent PIH.

Our lasers of choice for melasma include the Cynergy laser (595 nm, 1,064 nm, Cynosure), Fraxel Re:Store (1,550 nm) and the Cutera Limelight IPL (520 nm to 1,200 nm).

The vascular lasers are used primarily for those cases of melasma that contain a vascular component.

Patient selection

Skin type is also a factor in patient selection.

In our experience, patients with skin types I to III clinically appear to have a lower risk of recurrence after laser therapy for melasma.

In skin types IV to V, the risk of recurrence and postinflammatory hyperpigmentation increases dramatically.

Even with perfect patient selection, cases of worsening of melasma can occur. Explaining this possibility to patients prior to treatment is essential, as this problem often will arise.

Role of lasers

Do lasers play a role in the treatment of melasma? Our answer is yes, but limited to a select group of patients.

At the University of Miami, we use these questions to help decide those who may benefit from laser treatment:
1. Have topical therapies failed?
2. Is the condition chronic (not a temporary inciting factor)?
3. Is the pigmentation dermal?

If the answer to No. 1 plus any of the other questions is “yes,” then we will consider laser therapy.

Test spots in inconspicuous areas are an excellent option. Even with perfect patient selection, laser use on these patients must be performed conservatively.

Dr. Kaufman is assistant professor of clinical dermatology at the University of Miami Miller School of Medicine and director of lasers for the University of Miami Cosmetic Group. The Cosmetic Group is involved in research and development of lasers and light devices as well as other aesthetic procedures, such as fillers and toxins.

Dr. Woolery-Lloyd is director of ethnic skin at the University of Miami Cosmetic Medicine and Research Institute.