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

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


Lisa Zaleski DO LCDR MC USN,a* Sabrina Fabi MD,b and Mitchel P. Goldman MDb

aDepartment of Dermatology, U.S. Naval Medical Center Okinawa, Okinawa, Japan bDermatology/Cosmetic Laser Associates, La Jolla, CA
*The views expressed in this article are those of the authors and do not reflect the official policy of the Department of the Navy, Department of Defense, or U.S. Government.

mity of the pulse delivery. Intense pulsed light has been used to treat melasma, telangiectasias, spider nevi, rosacea, lentigines, postburn hyperpigmentation, erythrosis, poikiloderma of Civatte, photoinduced skin aging and to reduce hair.2,18The IPL activates fibroblasts, resulting in the synthesis of new collagen with wrinkle reduction, increased skin elasticity, contraction of larger pores, reduction of brown spots, and a decrease in telangiectasias.19 Side effects of IPL include a transient erythema and slight edema that resolve within 12 hours, PIH, and desquamating microcrusts for 7 to 10 days.3 The major problem in evaluating the peer-reviewed medical literature is that each IPL device has a unique set of parameters that makes it different from the others. Thus, when reviewing the IPL literature, the improvement and complication profile may not be 100% reproducible from one IPL device to another. Our experience, and most of the published literature, is with the Lumenis IPL systems (Santa Clara, CA), but even within one company, the IPL systems differ based on the model.
Intense pulsed light has multiple advantages over other lasers for the treatment of melasma. The longer wavelengths used with IPL allow deeper penetration for treatment of dermal melasma. The larger spot allows for more extensive areas of the face to be treated in a shorter time period, minimizing patient discomfort. There is also a decrease in nonhomogeneous resolution with a decrease in polka-dot treatment results with the IPL that can be seen with smaller laser round-spot sizes. In addition, there are fewer local or systemic effects because of the pulse delays in more advanced IPL systems, so the skin can be cooled between pulses.2 This decrease in photothermal injury leads to less PIH in comparison with Q-switched lasers.5
The IPL has been used in combination with the Q-switched ruby laser, with 19/25 (76%) of patients reporting good to excellent responses.20 Side effects mainly included PIH in 12% and linear hypopigmentation in 4%. The IPL was advantageous because of the minimal preoperative preparation, easy application, limited posttreatment care, and a lack of downtime. However, multiple treatments are often needed to obtain the desired results, and deeper-pigmented patches tend to be less responsive. The addition of the Q-switched ruby laser allows for deeper penetration of dermal melasma but a higher risk of PIH. Repeated IPL treatments could decrease PIH caused by the Q-switched laser. The pulse duration of IPL is in milliseconds, resulting in a greater thermal diffusion and a more generalized destruction of pigment. Quality-switched lasers are in a nanosecond range, which selectively targets melanosomes with decreased thermal diffusion.20
Poikiloderma of Civatte is similar to melasma, as both conditions involve hemoglobin and melanin as chromophores targeted with treatment. Goldman and Weiss reported a 50% to 75% clearance of telangiectasias and hyperpigmentation in poikiloderma with an average of 2.8 IPL treatments. There was a 5% incidence of mild pigmentary side effects. Improvement in skin texture was an added bonus with the IPL treatments.18,21
The successful use of IPL for skin rejuvenation has been well documented in the literature.17,22-24 Nootheti et al found a 40% improvement in photoaging after a single IPL treatment.25 Feng et al found an 84.6% pigmentation improvement and an 81.25% telangiectasia improvement after 3 IPL treatments.26 However, JØrgensen et al27 found the long-pulsed dye laser to be advantageous over the IPL in photodamaged skin because of superior vessel clearance and less pain associated with the procedure. Both the laser and IPL had similar efficacy with pigmentation clearance.27
Repigmentation with melasma eventually recurs, likely secondary to persistent triggering factors.5 We feel that IPL is the light source of choice for the treatment of dermal and mixed melasma because of its lower side effect profile and ability to target both melanin and hemoglobin as chromophores.17,21 Targeting the vascular component of melasma in addition to the pigmentation may be the key to improved results.
Our melasma patients demonstrate a strong correlation of vascularity with their melasma on the VISIA Complexion Analysis (VISIA, Fairfield, NJ). Currently, triple-agent therapy is the firstline treatment for melasma. The VISIA Complexion Analysis may be an easy method to determine which patients are the best candidates for concurrent IPL therapy.

DISCLOSURES

Drs. Zaleski and Fabi have no conflict of interest to declare. Mitchel P. Goldman MD is a stockholder and consultant to Lumenis Ltd. and a consultant to Obagi Medical Products, Inc.

REFERENCES

  1. Kim EH, Kim YC, Lee ES, Kang HY. The vascular characteristics of melasma. J Dermatol Sci. 2007;46(2):111-116.
  2. Campolmi P, Bonan P, Cannarozzo G, et al. Intense pulsed light in the treatment of non-aesthetic facial and neck vascular lesions: report of 85 cases. J Eur Acad Dermatol Venereol. 2011;25(1):68-73.
  3. Li YH, Chen JZ, Wei HC, et al. Efficacy and safety of intense pulsed light in treatment of melasma in Chinese patients. Dermatol Surg. 2008;34(5):693-700.
  4. Shin JW, Lee DH, Choi SY, et al. Objective and non-invasive evaluation of photorejuvenation effect with intense pulsed light treatment in Asian skin. J Eur Acad Dermatol Venereol. 2011;25(5):516-522.
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