Melasma combination therapy digs deep

New York - Treatments for melasma often fail because they do not address both the dermal and epidermal components of the condition, an expert says.

Arielle N.B. Kauvar, M.D., says that to date, “Unfortunately, our treatments for melasma have been relatively unsuccessful.” She is director of New York Laser & Skin Care and a clinical professor of dermatology, New York University School of Medicine.

Numerous topical combinations aim to reduce the skin’s melanin production, she explains. Chemical peels help some patients, but not others.

“And it turns out that the vast majority of laser treatments will not help, and often exacerbate melasma,” Dr. Kauvar says.

Most of the lasers used to treat melasma - such as various Q-switched and fractional lasers -cause inflammation because they operate at high energy levels, she says. Similarly, ablative lasers peel surface skin, a process that also can cause inflammation. Along with sunlight, it’s the key trigger in exacerbating melasma.

The dermal component

What makes melasma difficult to treat is the fact that most patients have pigment in both the epidermis and dermis, Dr. Kauvar says.

“If you use a peeling procedure or an exfoliating topical treatment, you can help the people with epidermal melasma, who generally do well. But the vast majority of people with melasma have a dermal component,” she says.

To help these patients, Dr. Kauvar says she has devised a treatment regimen that targets both the superficial and deep pigmentation in a non-traumatic way that avoids inflammation.

“Q-switched Nd:YAG lasers penetrate extremely deeply - up to 1 cm - and it doesn’t take much energy with these lasers to destroy melanosomes.”

Furthermore, she says, using energy levels so low as not to produce any pain eliminates the possibility of erythema and edema.

“I start with microdermabrasion, just to help penetration of the laser,” Dr. Kauvar says. Microdermabrasion eliminates the dead cell layer, reducing light scatter when the laser hits the skin. Microdermabrasion also stimulates skin exfoliation, she says.

“With the combination of microdermabrasion and the Q-switched Nd:YAG laser, we can break up sufficient amounts of pigment” that the immune system clears over time.

For optimal results, Dr. Kauvar says, patients typically require two to four laser sessions at one- month intervals. In a study involving 27 patients (skin types II through V) with refractory melasma, patients required an average of 2.6 treatments, performed at a fluence of 1.6 J/cm² to 2 J/cm² with a spot size of 4 mm or 6 mm, spaced one month apart.

Adding topicals

In addition to breaking up existing pigment with the laser, Dr. Kauvar says, patients typically require a topical regimen to suppress ongoing pigment production by hyperactive melanocytes. In this regard, study patients used a combination of hydroquinone 4 percent and tretinoin or vitamin C, as well as sun avoidance and daily application of water-resistant broad-spectrum sunscreen.

At follow-up assessments conducted three to 12 months after study patients’ final treatment, 22 subjects (81 percent) had greater than 75 percent clearance of melasma; 11 of these patients experienced greater than 95 percent clearance (Kauvar AN. Lasers Surg Med. 2012;44(2):117-124).

“Remissions lasted at least six months, and, in a substantial subset of patients, more than a year,” Dr. Kauvar says.

In her clinical experience, Dr. Kauvar says that a couple months after beginning the topical regimen, “The vast majority of patients already have noticeable improvement. Once they achieve more than 90 percent clearance, I will have them reduce the topicals,” by reducing the frequency of hydroquinone usage or replacing hydroquinone with an alternative skin lightener.

“If patients experience irritation or inflammation from a product,” Dr. Kauvar says, “they must call me right away.”

For patients who cannot tolerate hydroquinone or tretinoin, she prescribes alternative agents such as azelaic acid, kojic acid, vitamin C or arbutin. They are less effective than tretinoin and hydroquinone, Dr. Kauvar says, but they help to suppress melanin production.

Another useful agent is Elure (lignin peroxidase, Syneron), which uses enzymatic action to break up existing melanin.

“Since it breaks up the epidermal melanin but doesn’t address the dermal component, it should be used in combination with other agents,” Dr. Kauvar says.

Altogether, she says the regimen combining topical treatments and the Q-switched Nd:YAG laser represents “a tremendous step forward for melasma therapy. It’s a simple procedure that has no risk of adverse effects. We have never seen anyone flare from this treatment. And it’s safe to use on all phototypes, including type VI.”

Recently, small studies have begun showing promising results in melasma for the fractional 1,927 nm laser (Ho SG, Yeung CK, Chan NP, et al. J Cosmet Laser Ther. 2013;15(4):200-206). However, she says, “It’s important to follow these individuals long-term, because that procedure produces a lot of inflammation. And often, melasma will get worse after any kind of laser procedure that results in inflammation.”

Disclosures: Dr. Kauvar reports no relevant financial interests.