Dr. Saedi: We go over the whole face with two passes and then back to the areas of melasma, do one to two more passes making sure that it's not too hot.Dr. Burgess: For my conservative treatments of chemical peels and microdermabrasion, I will treat the entire face; however, I will spot treat with the laser device for the deep dermal pigmentation. To determine the depth of pigmentation, I will perform a Wood’s lamp examination and meximeter/colorimeter readings for quantitative measurements to baseline pigment. I can always determine if therapy is ineffective or there is increased sun exposure.Dr. Roberts: At first, I just treated areas of melasma but was eventually treating the whole face because I began to see it as pigmentation in the past, present, and future, especially in the mature patient here in the sun belt. For melasma this isn't a monotherapy. Now I recommend full face rejuvenation for melasma cases, I think they turn out better, and the whole result is very even.Dr. Chilukuri: I don’t want to say it’s a drug delivery system, but what I do is pre-treat with the laser, and if there's a small break in the skin that expands just a little bit, I apply a skin peel and get better results with fewer application passes. I use that combination quite often, but this is not my go-to laser, I may be the lone dissenter on that. I would go with a picosecond laser, especially for somebody who may not be as skilled because you can use very, very low fluences and no downtime. Some would argue that the pico might be even safer for melasma because it's a photomechanical effect, rather than photothermal. If you have to pick one device that does a lot of things with no consumables, however, 100% I would.Dr. Roberts: What about rebound pigmentation? Dr. Chilukuri: Typically, we use low fluences with the pico, but again, that's not the primary thing that I treat in my office, I usually refer out melasma patients. But you can paint it seven, eight, ten times, you're using such a low fluence, usually 0.6-0.7 J/cm2, doing a generalized photomechanical disruption.Dr. Saedi: I totally agree about the safety of the pico, we use often for melasma, but one issue is that with the pico you still unmask the vasculature that's there. And with the 650-microsecond 1064nm Nd:YAG you're treating the pigmentation and vascular components.Dr. Campbell-Chambers: I also use the combination treatment approach to melasma that Dr. Burgess and Dr. Chilukuri discussed. I use a peel with hydroquinone plus salicylic acid and lactic acid, after the laser. I tend to reserve it for refractory cases.Dr. Roberts: So not everyone is going right to the 650-microsecond 1064nm Nd:YAG laser for melasma but we’re using it often in combination. Any other tips for melasma? Dr. Henry: I also use topical tranexamic acid after the laser, that's been one of my favorite treatments. If I'm using hydroquinone, there is a non-irritating hydroquinone gel that I'll use immediately after as well.Dr. Burgess: I use the lowest setting possible, usually at level four or five in order not to expose the skin to a lot of heat.Dr. Chilukuri: I agree with the low heat and fluence. Like Dr. Burgess I use the laser in a paintbrush fashion across the skin, no double passes, breaking up the pigment. I usually follow with a hydroquinone peel. Another tip, if melasma patients have a special event I break protocol and treat weekly at very low fluence, just to break up that pigment. Then I'll use a triamcinolone or other mid-potency steroid to calm down the inflammatory response of the skin. We're often seeing good improvement as early as three to four weeks in all skin types, use a painting technique and then apply the triamcinolone and your hydroquinone or other at home treatment as normal.
Acne and Pseudofolliculitis Barbae (PFB)
Dr. Roberts: How does the device address the multifactorial nature of inflammatory and non-inflammatory acne? Dr. Burgess: I have a patient with chronic nodulocystic acne with an urticarial response who was not a candidate for isotretinoin because of pseudotumor cerebri. I treat her full face every two to three weeks to control her acne and improve the scarring; therefore, I would definitely recommend the 650-microsecond 1064nm Nd:YAG laser treatment for patients who are not isotretinoin candidates. Because she is Caucasian, I treat her at level 8. Within two to three days, the nodules diminish. She has home therapy of Vitamin 25,000 IU and topical prescription acne products to control her acne.Dr. Chilukuri: I've got somebody very similar who took an antibiotic, but it caused pseudotumor cerebri type symptoms, so she's gun-shy about orals. Her topical regimen was terrible, she had extra-dry skin and mostly nodular acne with some cysts (really a prime Accutane candidate), skin type V. We’ve cleared her active acne and continue maintenance treatments. I was treating her at the beginning every week to handle the cystic component. After three sessions we weren’t seeing new breakouts, so we went to treatments every two weeks, and now she's at monthly to improve scarring. Like everyone else I used combination topicals, plus a hyaluronic acid that will hopefully help repair the skin, and a non-comedogenic moisturizer with sun
