Dr Jaggi Rao, Dermatologist and Laser Surgeon from Canada presented his method of treatment of melasma.
Melasma is a common condition.
Brooke Burke, is an unlucky sufferer of the condition.
* Melasma is an acquired pigmentation of sun-exposed areas
* Usually brown, blotchy hyperpigmentation of the face, although it sometimes also occurs on the neck
* There is excess melanin in the epidermis AND the dermis.
* It is a melanotic condition, not a melanocytic condition
Melanotic = A condition characterized by abnormal deposits of melanin (especially in the skin)
Melancyte = a melanin producing cell located in the bottom layer of the skin’s epidermis
Melanocytic = Similar to or characterized by the presence of melanocytes
* Much more common in women than men.
* Usually occurs in women’s reproductive years
* In pregnancy = chloasma
* More common in light brown-skinned people ie Fitzpatric 3-5
* Hormonal influences coupled with UV light exposure
* 30% of patients have a family / genetic history
MSH, oestrogen, progesterone, ?TSH
* Pigmentation usually occurs in cheeks and other CONVEX areas. It is less common in concave areas. This may be caused by the dispersion of light in these areas. People with more convexity may get worse pigmentation at the apex.
Dr Rao never biopsies melasma as it is a clinical diagnosis only, it is symmetrical, on convexities in a certain patient demographic
Melanogenesis is a complex process where precursor molecules are acted upon by tyrosinase to produce melanin in organelles called melanosomes.
Melanized melanosomes (melanin packages) are then transferred from melanocytes to keraticnocytes eventually producing the apparent skin colour.
In the past doctors used to think that a Woods lamp could distinguish between epidermal and dermal melasma. The way that Dr Rao now determines whether melasma has also extended into the dermis is by taking a history ie if a patient has had melasma for over 1 year then there will be some dermal melasma present as well as epidermal.
Melasma Treatment is Frustrating!
The difficulties are that given that the issue is often in the dermis, then topical and some laser treatments don’t work very well on the dermal pigment.
The other difficult side of the coin is that with too aggressive treatment there is a risk in these patients of post-inflammatory hyperpigmentation.
Melasma Treatment Philosophy
Prevent Pigment Gain
* UV light protection
* Hormonal control
* Prevent Melanization
Promote Pigment Loss
* Exfoliation (ie get the cells to slough off)
* Pigment Relocation (can we relocate the pigment eg to another organ
* Ablation (ie vaporising the pigment)
Prevent Pigment Gain
* Sun AVOIDANCE and Broad spectrum sunscreen
* Ideally a physical block
* Use ALWAYS, including indoors and outdoors
Avoid UV light AT ALL COSTS because it will only take small amounts of UV to initiate the process of melasma
* Hormonal Workup
* Not usually warranted, and usually show normal findings.
Do consider in sudden onset melasma and with other hormonal signs and symptoms. Dr Rao saw a patient who had a breast tumour and melasma was the only sign.
* Prevent Melanization
* Topical Agents
Lightening Agents for Melasma (don’t call them bleaching creams!)
* Enzymatically inhibits Melanin synthesis and melanization
* Complications of Hydroquinone:
– Skin irritation
– phototoxic reactions
– PIH (can occur with higher concentrations)
– ochronosis (can occur with higher concentrations) risk is very low and can be treated
* Azelaic Acid
* (20% topical formulation)
* Targets hyperactive melanocytes
* Skin irritation
* Kojic Acid, Acorbic Acid, mequinol, Phenolic Acid, Niacinamide, Liquorice derivatives and the list goes on…….
Mild irritation from these acids causes exfoliation, which is good to a point which is where the patient experiences discomfort. The way Dr Rao manages the skin irritation is by suggesting the following protocol
When using his favourite topical treatment for melasma (Hydroquinone 5%, Hydrocortisone 2% in tretinoin 0.025% cream). He suggests using this cream for 10 minutes daily for a few days, then 30 minutes daily for a week, then 1 hour, then 2 hours then 3 hours. Once the patient gets to 3 hours he finds that they can leave it on all night.
Promote Pigment Loss non-laser/light based
* Retinoids (eg tretinoin, adapalene, tazarotine etc
Used in “Triple Combination (ie tretinoin, HQ, corticosteroid)
* Chemical Peels
– Glycolic Acid, TCA, Jessners etc
– Aggressive treatment can make melasma worse
– Penetration capacity is limited
Dr Rao is not a fan of chemical peels because of the risk of PIH
Often too superficial and therefore not very effective
* Dermal Rolling
Dermal rolling doesn’t work very well for exfoliation
Promote Pigment Loss with laser/light based devices
* Light Therapy
* BBL (flashlamp Non-coherent light source)
– Can be very useful to reduce the intensity of melasma. It works by EXFOLIATION
– Will often reach a plateau of improvement, difficult for mild melasma
* Non-ablative Lasers
– Fractionated IR lasers, other energy sources (eg RF, US)
* Non-ablative Lasers
– Q switched Pigment Lasers can be very effective for superficial melasma (eg Ruby, Alex, Nd:YAG)
– Avoid long pulsed lasers, they have a high risk of causing melasma to get worse due to PIH
ABLATION OF PIGMENT
* Full Contact / Full Field Laser Resurfacing
* May help superficial melasma via exfoliation
* Can make melasma worse if too much heat delivered to the skin, because heat can cause PIH
* The difficulty with full field resurfacing is that it’s impossible to reach the depths required to ablate the dermal melasma. Full field resurfacing can’t pass into the dermis
* Fractionated lasers
* Non-ablative lasers are not useful for deep melasma
* Ablative fractional lasers
– Are useful for the treatment of dermal melasma because our aim with them is to ablate excess pigmentation in the path o of the laser, with reduced collateral heat injury.
– The MTZ or channels of ablation provide an avenue for transepidermal elimination. So the pigment is ablated, but also the MTZs can exude the pigment which surrounds the MTZs
Fractional Laser Treatment of Melasma
* Leaves Bridges of intact skin
* Speeds up healing and decreases downtime
* Provides a more comfortable treatment experience
* Diversity of Skin Types and Applications
How does fractional laser work to treat melasma?
The MTZs cause ablation of a proportion of pigment and allow exudation of surrounding pigment through the channels created by the laser.
Pigment exudes to the surface
Comparing Ablative Fractional Lasers for Melasma Treatment
Here Dr Rao compares the difference between Erbium(Profractional Laser), YSGG (Pearl Fractional Laser), and CO2 Fractional Laser.
The difference between all of these lasers is the amount of coagulation around the MTZs.
All 3 of these lasers have MTZs, ie columns of ablation where the laser passes. The difference between them is the amount of coagulation around the MTZs.
Erbium YAG Laser
Has very little tissue that is heated around the columns of ablation / MTZs. So there is little collateral damage
Co2 is the opposite of Erbium Laser in that there’s lots of damage (protein denaturation/coagulation) around the MTZs
YSGG (eg Pearl) laser
Is halfway between the Erbium YAG and the CO2 laser in that there is a moderate area og coagulation or damage around the column of ablation
What is the best laser for treatment of melasma?
Dr Rao uses the Sciton Joule (as do I). With Melasma we want minimal heat and minimal collateral damage, due to the risk of PIH.
The Sciton Joule is Dr Rao’s go-to choice for the treatment of melasma. He has many other brands and devices available to him in his clinic. He uses it on a daily basis
Dr Rao’s Melasma Laser Regime
* Dr Rao ALWAYS includes the profractional Laser as part of the regime
* General initial Parameters for consideration. Always start conservatively
-400 um 11% for lighter skintypes (Fitz 3-4)
– 200 um 11% for darker skintypes (Fitz 5)
At these initial parameters, he has no cases of PIH.
For lighter skin types, he will go up to 25% pitch.
* REMEMBER, once the pigment has reduced to a satisfactory level continue with the philosophy of “Preventing Pigment Gain”
Dr Rao has treated 100s if not 1000s of cases with great results
400 um is more efficacious than 200 um but he got more cases of PIH in darker skin tones. A higher pitch also causes PIH.
Asian skin gets great results, Dr Rao doesn’t have to worry as much about PIH compared with Fraxel laser, because with the 2940 wavelength is very specific for water. It heats it to 100 degrees and vaporises it with minimal spread.
If the patient also has acne scarring, then coag should be added for the collagenesis effect.
He has a consultation and puts patient on lightening regime for a minimum of 2 weeks, the patient will continue this until the day of the procedure. The patient will then resume the topical regime after healing has occurred eg 5 days.
Patients should wait 2 months until next profractional laser treatment. There is no limit to the number of treatments a patient can have, as long as they are 2 months apart.
11% pitch can only get at best a 25-50% improvement
Is Melasma Curable?
No. Treatment only achieves a remission. Melasma will always rebound over time.
He has used Ablative Fraxel on patients, but it has a higher risk of PIH.
Anaesthetic for profractional laser
At 400 microns, he gets away with topical anaesthetic.
He uses 7% lidocaine 7% prilocaine. They apply it 2 hours before the treatment, wipes off each region at a time.
BBL for melasma
Dr Rao uses BBL first. If the melasma is predominantly epidermal, the BBL will work very well (also it is a cheaper treatment)
* BBL very good for epidermal melasma
* Use extreme caution NOT TO OVERHEAT the skin, consider test patches “Start low, go slow”
* General parameters
– Large spot sizes
– 590 or 560 filter (he doesn’t use 515, but I do and others do)
– 15-20 degrees cooling
– single pass with multiple treatment sessions, gradually increase fluence by 1-2 J/cm2 with each session
– Dr Rao believes 560 filter is great for redness and small freckles.
– Dr Rao separates BBL and fractional laser by 1 week
– Dr Rao would always test patch BBL with Type 5 skin
Why doesn’t non-ablative fractional resurfacing laser work as well as ablative for melasma?
Dr Rao thinks this is because of the transepidermal channels which allow pigment to be extruded to the surface.
With non-ablative fractional laser there’s no ablation, therefore no physical hole to the epidermis for the pigment to be released to the surface. The pigment has nowhere to go. Therefore, non-ablative fractional resurfacing only works for epidermal melasma.
1.Asian skin tone melasma
BBL 515 12/15/20 = profract 75microns
2. Light asian skin tone melasma
BBL 560 filter, profrac XC 150 microns 11%
3. darkness on vermilion border, he would use profractional rather than BBL