Treatment of Melasma and the Use of Intense Pulsed Light: A Review

November 2012 | Volume 11 | Issue 11 | Original Article | 1316 | Copyright © November 2012

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The pathogenesis of melasma is important when considering laser treatment. Kim et al1 reported increased vascularity as a major finding in melasma with increased amounts of VEGF and blood vessels within melasma lesional skin. It has been postulated that ultraviolet (UV) radiation-induced dermal inflammation activates fibroblasts and stem cell factors in melasma dermal skin, causing melanogenesis. The increased vascularity could be why melasma occurs in select regions and not uniformly across the face, despite equal UV damage.
Vascular endothelial growth factor has also been shown to stimulate the release of arachidonic acid, and the metabolites of this pathway may affect melanogenesis. Steroids in triple-agent creams used to treat melasma can also induce telangiectasias, possibly exacerbating this component of melasma.1 Bak et al8 reported increased nerve growth factor and neural endopeptidase in melasma lesional skin, also suggesting its association in the pathogenesis of melasma.
Multiple studies have shown varied effectiveness of lasers in the treatment of melasma. The nonablative 1,550-nm fractional laser has been used to treat melasma with greater patient satisfaction 3 weeks after treatment compared with topical triple-agent therapy of HQ 5%, tretinoin 0.05%, and triamcinolone acetonide 0.1% cream. It was thought the laser brought greater satisfaction early on because of a faster initial clearance and a possible increased effectiveness in treating dermal melasma. However, 6 months posttreatment, the pigmentation returned in both treatment groups with equal patient satisfaction rates. Side effects of the 1,550-nm laser treatment included erythema, burning sensation, edema, and pain. Kroon et al6 noted no postinflammatory hyperpigmentation (PIH) with this treatment modality using conservative settings.
Wind et al9 described the use of the nonablative 1,550-nm fractional laser in the treatment of melasma, and 9 patients (31%) developed PIH after 2 or more laser sessions. The increased PIH seen in the study is likely secondary to more aggressive treatment settings. Skin findings and side effects associated with topical triple-agent therapy included erythema, scale, and burning. Triple-agent topical therapy is still the treatment of choice because of similar efficacies 6 months posttreatment.10-11
The Q-switched Nd:YAG laser has also been reported to temporarily improve melasma with common complications, including hypopigmentation, melasma recurrence, and rebound hyperpigmentation. Transient erythema, transient burning, and slight edema occurred for 1 hour postprocedure. Wattanakrai et al12 found decreased epidermal and dermal pigmentation for up to 1 year after 10 weekly treatments with the Q-switched Nd:YAG laser at subthreshold photothermolytic fluencies (<5 J/cm2). However, rebound hyperpigmentation was common, and the risk of mottled hypopigmented macules increased with greater number of laser sessions.12,13 Narrowband UVB has successfully been used to treat depigmentation with good clinical results.13 The short-pulsed deep Er:YAG laser temporarily but effectively reduces epidermal type melasma, with a recurrence upon discontinuation of treatment.14
A review of the literature suggests that laser and light source treatments can result in rebound hyperpigmentation, relapse, and darkening of melasma. It has been postulated that the laser unmasks a previous subclinical melasma. This is thought to be secondary to stimulation of hyperactive melanocytes, which can increase melanin production and therefore pigmentation.15
Intense pulsed light is a noncoherent filtered flashlamp light source, emitting light between 515 and 1,200 nm. Filters allow for selective photothermolysis of chromophores, including melanin and hemoglobin.5,16 Since its introduction in 1992, there are now more than 20 different IPL devices available worldwide.17 Each IPL device has a unique set of wavelengths, fluences, pulse durations, epidermal temperature effects, and other pulse parameters in addition to duration, such as unifor-