The following roundtable is edited from discussion between the authors concerning treatment with the 650-microsecond 1064nm Nd:YAG laser. These dermatologist experts share their expertise, experience, and treatment pearls regarding the device for medical and aesthetic use, and in treatment of skin of color (SOC).
Melasma in Skin of Color
Dr. Roberts: The 650-microsecond 1064nm Nd:YAG laser is ideal for six out of the top ten indications for SOC, including melasma. Prior to this device, was there one specific laser you used on your SOC patients? Did you alternate between devices? How has this changed and why?Dr. Henry: I used multiple devices, but with this we have a go-to device for SOC that my patients are very comfortable with because of the safety level.Dr. Burgess: Distinguishing factors like pulse duration make a difference between Nd:YAG lasers. The 650-microsecond 1064nm Nd:YAG is my go-to laser device. For melasma, I begin the treatment with non-laser or light devices due to the exacerbation of melasma with heat. The 650-microsecond laser device seems to generate the least amount of heat to provoke a rebound effect. Additionally, we recommend wearing physical sun protection, avoiding sun exposure and extreme heat. I typically treat with hydroquinone (not higher than 6%) several times a week with alternating non-hydroquinone blending products. After several weeks of home therapy, I chemically peel the skin with Jessner and salicylic acid peels to mitigate inflammation. I may alternate with microdermabrasion. For stubborn areas, I go to my 650 microsecond 1064nm Nd:YAG laser device every 3-4 weeks because you need time for phagocytosis of pigment.Dr. Roberts: And you've noticed decrease in rebound pigmentation? Dr. Burgess: Yes, I see less rebound pigmentation with the 650- microsecond 1064nm Nd:YAG device when I compare it to my Q-switched short pulse and long pulse Nd:YAG devices.Dr. Roberts: In my experience it’s great for those islands of darker skin within patches of melasma. Comments?Dr. Chilukuri: We use a similar protocol involving topicals and peels. I use the device mostly for refractory melasma. With melasma, we're targeting different aspects: epidermal pigment, dermal pigment, and upper dermal pigment as well as the vasculature. Peels treat epidermal melanin but not so much deeper. The laser will break up some epidermal pigment, but with the microsecond technology we’re more specific to that deeper dermal melanin and vasculature that peels cannot treat.Dr. Roberts: Do you go for rejuvenation at the same time or just target hyperpigmentation?Dr. Chilukuri: I consider the rejuvenation effect anytime we have an opportunity to heat collagen and improve the skin texture and quality. I'll do full-face, two or three passes, maybe four, focusing on darker areas with a few more passes. I've trained our staff to feel the skin with the back of the hand as you would a child with a fever, to make sure we're not getting too much heat. As Dr. Burgess said, if we cause too much heat, we're inducing rebound hyperpigmentation.Dr. Henry: I do it the same way, picturing the treatment area as gradients with more passes on darker areas feathering out to normal skin.