Menegament of Melasma

with

Ablative Laser Treatment ŞERAFETTİN SARAÇOĞLU, MD

DERMATOLOGIST

MELASMA

Acquired

Symetric

Hypermelanosis

Age 30-55 years

♀/♂: 90/10

Epidermal

Dermal

Mixt

Mechanism of action of main bleaching

agents used to treat melasma (adapted

Gupta et al., 2006)

Mecanism of action Substance

Tyrosinase inhibition Hydroquinone

Tretinoine

Azelaic acid

Kojic Acid

Non-selective suppretion of

Melanogenesis

CS

İnhibition of ROS Azelaic acid

Melanin removal Chemical peeling

Thermal damage Lasers

Melasma Laser Treatment

Non –ablative

Q-SW Ruby

Q-SW Alexandrite

Q-SW Nd-YAG

Cu-Bromide

FLPDL

IPL

Ablative

CO2

Er-YAG

Thulliım

Ablative Laser Treatment of

Melasma

Laser resurfacing

Fractional resurfacing

Laser resurfacing; Er-YAG

• Rhesa May at al.,

• Postpeel results

• Imidiate results excellent

• 3rd-6th week PIH (universal, all patients)

• GA peeling beweekly

• Bleaching regimen

• 6th month MASI score significantly decreased

• Conclusion: Perform just for refractory melasma patients

• Rhesa May, P. Manaloto and Tina Alster. “Erbium:YAG Laser Resurfacing for Refractory Melasma.” Dermatologic Surgery 1999 : 121

Melasma;

Ablative Laser Treatment with Er-YAG

Manaloto et al., 1999

CS, N=10

ER-YAG ( Continuum Biomedical, Dublin, CA) 1-1.5 J (5.1-7.6J/cm2), 5

mm spot, 8 Hz

PIH 3-6 weeks after procedure

Azelaic acid 20% cream, GA peeling beweekly

Manaloto RMP, Alster TS. Erbium:YAG laser resurfacing for refractory melasma. Dermatol Surg.1999;25:121–3

Fractional laser (nonablative)

RokhsarCK, Fitzpatrick RE. The treatment of melasma with fractional photothermolisis: A Pilot study. Dermatologic Surgery. 2005;31:1645-50

Geronemus, R. G. (2006), Fractional photothermolysis: Current and future applications. Lasers Surg. Med., 38: 169–176. doi: 10.1002/lsm.20310

Goldberg DJ, Berlin AL, Phelps R. Histologic and ultrastructural analysis of melasma after fractional resurfacing. Lasers Surg Med. 2008;40:134–8

Non-abalative Fractional treatment has signficant improvement effect on the melasma pecthes Melanocyte count is decresed

But at 6th month follow-up, recurrence was noted in 50% patients

Melasma;

Fractional Ablative Laser Treatment with

Er-YAG

Wanitphakdeedecha et al, 2009

CS, N=20 ♀, Epidermal Melasma, 2 treatments 1 month apart

VSP Er-YAG ( FidelisM320A, Fotona, Ljubliana, Slovenia) 160 mJ(0.4

J/cm2), 300 µs PW, 7 mm spot, 10 Hz

PIH (n=3)cleared spontaneously within 2 weeks

Acneiform eruption (n=2) treated with clindamycin and adapalene

15% of patient had 50 % improvement

Melasma;

Fractional Ablative Laser Treatment with

CO2 Trelles et al., 2010 RCCT

30 woman FSP II-V

GroupA. Kligman’s formula + TT2 ☼ cream (n=10)

GroupB. CO2 laser ( n=10)

GroupC. CO2 laser + TT2 cream ( n=10)

Laser: Ultrapulse Active FX Lumenis, Yorknaem, Israel) 7.5 W, 150 mJ( (11.3 J/cm2), 350 ms PW, 50 Hz

1st mounth A,B,C groups absence of complications

QoL index 100% all groups

MASI score decreased A,B group 12 mounth of follow-up, stabil at C group

TrellesMA, Velez M, Gold MH. The treatment of melasma with topical creams alone, CO2 fractional ablative

resurfaceing, or a combination of the two: a comperative study. J. Drugs Dermatol. 2010; 9:315-22

☼ TT2: Hydroquinon2%,Kojic acid 2%, GA

Melasma;

Fractional Ablative Laser Treatment with

Thullium Laser Polder et al.

CS, N=14

Thullium Fiber Laser ( Fraxel Dual, Solta Medical, USA)10-20 mJ, 252-

784 MTZ/cm2,

3-4 treatment, 4 week intervals

51% improvement, PIH (-)

34% MASI score at 3rd-6th month post treatment follow-up

Polder KD, Bruce S. Treatment of melasma using a novel 1,927 nm fractional thulium fiber laser: A pilot study. Dermatol Surg. 2012;38:199–206

Melasma;

Combined Ablative + Non-ablativeLaser

Treatment Idea;

Ablative: Remove epidermal melanin & melanocyt

Non-Ablative: Remove melanin in dermal melanophages

Angsuwarangsee et al.

N=6,

Right: QSAL

Left: Ultrapulse CO2 + QSAL

Significant response combination treatment site

Contact dermatitis & PIH

Hence: Just for refractory melasma Angsuwarangsee S, Polnikorn N. Combined ultrapulse CO2 laser and Q-switched alexandrite laser compared with Q-switched alexandrite laser alone

for refractory melasma: Split face design. Dermatol Surg.2003;29:59–64

Coclusion

In the management of melasma with ablative lasers is controversial

Thullium laser seems to promissing laser type for epidermal melasma

Needs further investigation

Topical bleaching agents remain the gold standart treatment

Combining pre&post laser and topical treatment greater efficacy

compared to treatments alone

Melasma; My Treatment Approach

Topical Treatment

Kligman formulation or TTT

Dermamelan peeling system

Sunscreen SPF 30+ or opaque

Oral Medication

Tranexamic acid 1500 mg/day PO

NAC 400 mg/day PO

Mesotherapy

Tranexamic acid + NAC +Vit-C equal, 0.01 ml/ cm2 weekly intervals

Laser

FPDL 585 nm, 7 mm spot, 2-2.5 J/cm2

Q-SW Nd-YAG 1064 nm, 6 mm spot, 0.6-1 J/cm2

Dermamelan Peeling

Before 3 Month after

Melasma + PIH

Before 8 Month After

Melasma + PIH

Before 5 Month after

Melasma PIH

Before 5 Month after

Thank you Serafettin Saracoglu, MD