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Therapeutic Efficacy and Safety of Invasive Pulsed-Type Bipolar Alternating Current Radiofrequency on Melasma and Rebound Hyperpigmentation

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Medical Lasers; Engineering, Basic Research, and Clinical Application 17
Original Article
Therapeutic Efficacy and Safety of Invasive Pulsed-Type Bipolar
Alternating Current Radiofrequency on Melasma and Rebound
Hyperpigmentation
Background and Objectives
Laser treatment for melasma is typically associated with various
complications, especially rebound hyperpigmentation (RH) and mottled
hypopigmentation. The purpose of this case review was to analyze the
clinical efficacy and safety of using an uinvasive pulsed-type bipolar
alternating current radiofrequency (IBPRF) for treating melasma with or
without RH.
Materials and Methods
Clinical improvement in the appearances of melasma and RH was analyzed
in 142 Korean patients (4 men and 138 women, with a mean age of 37.3 ± 11
years), who had undergone IBPRF treatment for melasma. IBPRF was
delivered at a frequency of 2 MHz and with non-insulated, penetrating
microneedles over five to 10 treatment sessions at 2- to 3-week intervals.
Results
In total, 124 patients had melasma, and among them,18 patients had
melasma with RH. To treat melasma, IBPRF alone was administered to
112 subjects, IBPRF plus a Q-switched Q-switched neodymium-yttrium-
aluminum-garnet (Nd:YAG) laser in 22 patients, IBPRF plus intralesional
tranexamic acid injection in five patients, and IBPRF plus bleaching
cream in three patients. Patients reported subjective satisfaction with the
appearance of their melasma lesions after seven to eight treatment
sessions, regardless of whether they underwent treatment with pulsed
RF alone or combination treatment. After treatment, no significant
complications, particularly RH or mottled hypopigmentation, were
recorded.
Conclusion
No severe complications related to IBPRF treatment were recorded, and
patients reported satisfaction in the appearance of their lesions after
seven to eight treatment sessions. This suggests that IBPRF may be
effective and safe for treating melasma and RH.
Key words
Invasive pulsed-type bipolar radiofrequency; Melasma; Postinflammatory
hyperpigmentation; Rebound hyperpigmentation
Hyoung Moon Kim
Min Ji Lee
Miaero Clinic, Seoul, Korea
Received June 19, 2017
Accepted June 21, 2017
Correspondence
Hyoung Moon Kim
Miaero Clinic, 164 Gwanak-ro, Gwanak-gu, Seoul
08788, Korea
Tel.: +82-2-871-7711
Fax: +82-2-876-7791
E-mail: drmac12@me.com
C
Korean Society for Laser Medicine and Surgery
CC
This is an open access article distributed under the
terms of the Creative Commons Attribution Non-
Commercial License (http://creativecommons.org/
licenses/by-nc/4.0) which permits unrestricted non-
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medium, provided the original work is properly cited.
Med Laser 2017;6(1):17-23
https://doi.org/10.25289/ML.2017.6.1.17
pISSN 2287-8300eISSN 2288-0224
Original Article
Medical Lasers; Engineering, Basic Research, and Clinical Application
18
INTRODUCTION
Melasma is a commonly acquired hyperpigmentary
disorder characterized by light to dark brown macules
and patches occurring along the sun-exposed areas of
the face and neck.1 The treatment of melasma remains a
challenge. Numerous treatment options, including topical
agents, chemical peels, and laser treatments, have been
applied for treating melasma.1 Q-switched pigmentary
lasers have not been recommended for melasma treat-
ment due to a high incidence of postinflammatory hyper-
pigmentation (PIH) and unpredictable efficacy.1 Intense
pulsed light has shown some efficacy in the treatment
of melasma, although the risk of PIH still remains high.2
Fractional laser treatments have also been reported to
improve melasma. However, a recent report showed that
the therapeutic efficacy of fractional lasers did not differ
from that of conventional therapies.3
Recently, a 1064-nm Q-switched neodymium-yttrium-
aluminum-garnet (Nd:YAG) laser with low energy was in-
troduced for the treatment of melasma in Asian patients,
with favorable results.4-6 Patients experienced minimal
downtime without crust formation and significant erythe-
ma after laser treatment. Notwithstanding, the possibility
of rebound hyperpigmentation (RH) and punctate leuko-
derma have since been found to be the major concerns
for this treatment.7,8
Studies have shown that the skin behaves like a semi-
conductor.9 When emitted on the skin, radiofrequency
(RF) elicits epidermal and dermal heating. Electrical
conductivity is an important factor affecting RF conduc-
tion, and research has shown that tissue hydration and
temperature are important conductivity factors.10,11 When
RF current is applied to the skin, an electrobiological
change is elicited therein. At a minimal pulse duration,
however, little to no change in the epidermis and dermis
can be achieved: “pulsed” describes intermittent dura-
tions during which the laser is switched on and off. None-
theless, with time, various changes in the skin have been
recorded.10 The purpose of this study was to evaluate the
clinical efficacy and safety of treating melasma and RH
with invasive pulsed-type bipolar alternating current ra-
diofrequency (IBPRF) with non-insulated needles.
MATERIALS AND METHODS
Patients and radiofrequency treatment
The present study was conducted as a review of medi-
cal records for 142 patients who underwent treatment
with IBPRF for melasma with or without RH. The patients
were clinically diagnosed with melasma. After obtain-
ing written informed consent, melasma lesions with or
without RH were treated with pulsed-type RF in a bipolar
mode, at a frequency of 2 MHz, and with a disposable tip
comprising 25 non-insulated, penetrating microneedles
in a uniform 5 × 5 array (SYLFIRMTM; Viol, Kyunggi, Korea)
(Fig. 1). At baseline and one month after the final treat-
ment, photographs were taken under normal and ultra-
violet light exposures with an imaging tool to evaluate
improvement in the appearance of treated lesions.
All procedures using IBPRF were performed after ap-
plying local anesthesia with topical EMLA cream (eutectic
mixture of 2.5% lidocaine HCl and 2.5% prilocaine; Astra-
Zeneca AB, Södertälje, Sweden). Parameters for IBPRF
were set at level III and a 1.5-mm penetration depth over
a single session for treatment along the face and at level
II and a 1-mm depth for treatment along the forehead.
Overall, five to 10 treatment sessions were proceeded at
intervals of 2 to 3 weeks. Immediately after treatment, a
hydration mask pack was applied. Neither systemic nor
topical corticosteroids and antibiotics were prescribed
prophylactically to most of the patients. The patients were
recommended to apply a broad-spectrum sunscreen and
avoid excessive sun exposure during the course of laser
treatments.
Combined treatment
Among the 142 patients treated with IBPRF, a com-
bination of IBPRF plus a Q-switched Nd:YAG laser was
applied in 22, IBPRF plus intralesional tranexamic acid
injection was administered in five, and IBPRF plus bleach-
ing cream was applied in three. In each of the 22 patients
treated with a Q-switched Nd:YAG laser, the whole face
was treated with a 1,064-nm Q-switched single pulse
Nd:YAG laser with the settings of 1.0-1.2 J/cm2, a pulse
duration of 5-10-nsec, and a 7-mm spot size. A total of
Distance
:2mmNeedle
Length:3.5 mm
Thickness
: 0.3 mm
Fig. 1. Schematic illustration presenting the characteristics of
microneedle electrodes in a disposable tip.
Invasive Pulsed Bipolar Radiofrequency
Hyoung Moon Kim and Min Ji Lee
VOLUME 6 NUMBER 1 JUNE 2017 19
Original Article
2,000 to 2,500 shots were delivered on the entire face. The
IBPRF treatments were performed immediately there-
after. Intralesional tranexamic acid injection therapy was
delivered immediately after IBPRF treatment.
RESULTS
Over 1 year, a total of 142 patients underwent IBPRF
treatment for melasma with or without RH. Of these, 97%
were female and 3% were male. Fifteen patients reported
having had melasma for less than 1 year, 64 patients stat-
ed between 1 to 5 years, and 53 patients reported having
melasma for longer than 5 years but less than 10 years.
There were 10 patients who had melasma for more than
10 years. Regarding melasma types, 103 patients pre-
sented with melasma of centrofacial type, while the other
27 patients exhibited melasma of malar type.
Among all patients, 124 reported that they had not pre-
viously undergone treatment for melasma, while 18 had.
Of these 18 patients, laser toning was most commonly
used for melasma treatment, followed by treatment with
intense pulsed light or whitening ointment. Some had
also received combination treatment with a fractional
laser, tranexamic acid injection, and polydeoxyribonucleo-
tide injections. All 18 patients had undergone basic treat-
ment with laser toning combined with other treatment.
For melasma treatment, IBPRF alone was adminis-
tered in 112 subjects. A combination of IBPRF plus a Q-
switched Nd:YAG laser was applied in 22, IBPRF plus
intralesional tranexamic acid injection was administered
in five, and IBPRF plus bleaching cream was applied in
three. Surprisingly, patients generally reported subjective
A
B
Fig. 2. Representative photographs of a 46-year-old female patient with recurrent melasma. (A) Baseline and (B) one month after ten sessions of
invasive pulsed-type bipolar alternating current radiofrequency (IBPRF) monotherapy.
Medical Lasers; Engineering, Basic Research, and Clinical Application
20
satisfaction with the appearance of their melasma lesions
after seven to eight treatment sessions, regardless of
whether they underwent treatment with pulsed RF alone
or combination treatment (Figs. 2-4). Furthermore, most
of the patients exhibited overall clinical improvement in
skin texture and tone.
During the course of IBPRF treatment and follow up,
no significant complications, particularly RH or mottled
hypopigmentation, were recorded. The most common
complication was induration at the treatment area due to
excess exposure to radiofrequency energy; it disappeared
within 2 to 3 days of applying steroid ointment. Moreover,
no other side effects, including bruise, bleeding, oozing,
prolonged erythema, folliculitis, acneiform eruption, and
scarring, were encountered.
DISCUSSION
In the present study, we aimed to determine the clini-
cal efficacy and safety of treating melasma and PIH with
pulsed RF treatment. In 142 patients, IBPRF treatment
was delivered at a frequency of 2 MHz and with non-
insulated, penetrating microneedles over five to 10 treat-
ment sessions at 2- to 3-week intervals. After treatment,
no significant complications, particularly RH or mottled
hypopigmentation, were recorded.
Generally, melanin is not believed to be influenced by
RF treatment. We, however, suggest that morphological
or functional melanin structures are directly changed
upon RF irradiation of melasma lesions. The electrical
properties of melanin have been shown to be somewhat
unique, displaying both electrical conductivity and photo-
A
B
Fig. 3. Representative photographs of a 37-year-old female patient with melasma. (A) Baseline and (B) one month after six sessions of combined
IBPRF and laser toning treatment.
Invasive Pulsed Bipolar Radiofrequency
Hyoung Moon Kim and Min Ji Lee
VOLUME 6 NUMBER 1 JUNE 2017 21
Original Article
conductivity. Eumelanin, one of three basic forms of mel-
anin, shows pronounced electrical conductivity, both dark
and photo induced. Under certain humidity, temperature,
and electric field conditions, solid eumelanin pellets ex-
hibit threshold and memory switching.12 The electrical
properties (light, dark, DC, and AC) of eumelanin appear
to be dominated by the hydration state of the tissue, in
which a large range of DC electrical conductivities are re-
ported (10-15-10-13 S/cm).12 Based upon a typical Mott–Da-
vies model, activation energies have been calculated from
temperature dependent conductivity measurements,
from which a wide range of values are reported (c. 0.5 -
3.4 eV). Meanwhile, however, de Albuquerque et al. (2005,
2006) recently reported a value of 1.7 eV in synthetic eu-
melanin films using photo-pyro-electric spectroscopy.13
In addition to the above, RF treatment also appears
to stimulate healing of the basement membrane (BM).
Indeed, electrical current has been found to help induce
wound healing.14,15 Recently, pendulous melanocytes
have drawn greater interest in melasma treatment. High
energy laser treatment targets the BM, after which pen-
dulous melanocytes shift downward into the dermis.16 We
suggest that RF irradiation thickens and heals damaged
BMs for improvement in PIH.
Alternating current focuses along the outer surfaces of
conductors. This phenomenon is called the “skin effect”.17
This effect is beneficial to melasma treatment and pre-
venting PIH. For example, for fine vessels in the reticular
dermis, if the resistance of the reticular dermis is 400
mohm and the intravascular resistance is 0 mohm, alter-
nating current will accumulate on the vascular surface,
since vessels behave as conductors (Fig. 5). Thus, pulsed
A
B
Fig. 4. Representative photographs of a 56-year-old female patient with melasma and rebound hyperpigmentation. (A) Baseline and (B) one month
after eight sessions of IBPRF monotherapy.
Medical Lasers; Engineering, Basic Research, and Clinical Application
22
RF targets the vascular surface, and then, selective ves-
sels with a certain diameter are destroyed. Large ves-
sels remain intact due to the “sink effect,” which is more
important than the skin effect: the sink effect refers to
moving fluid (blood) that takes away heat energy from the
conductor surface. Thus, the selectivity of RF treatment
for vessel diameter can be applied to melasma or vas-
cular treatment to improve diffuse erythema after IBPRF
treatment.17
The dermal environment is also improved after RF
treatment. We suggest that, first, RF accelerates washing
out of dermal melanin, followed by stimulation of neocol-
lagenesis.18 This improved dermal environment helps
boost melasma and PIH treatment results. Nevertheless,
our propositions should be verified in biopsied results,
and the safety range of pulsed RF should be confirmed.
In conclusion, no severe complications related to IB-
PRF treatment were recorded in the present study, and
patients reported satisfaction in the appearance of their
lesions after seven to eight treatment sessions. Our expe-
riences suggest that IBPRF is effective and safe for treat-
ing melasma and RH.
ACKNOWLEDGEMENTS
We would like to thank Anthony Thomas Milliken, ELS
(Editing Synthase, Seoul, Korea) for his help with the edit-
ing of this manuscript.
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Fig. 5. Electrical current accumulates on the surface of the conductor
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AC electrical current
Vessel wall
Electrode
0m
400 m
Electrical current
Dermis
Vessel lumen
(blood flow
= water)
Invasive Pulsed Bipolar Radiofrequency
Hyoung Moon Kim and Min Ji Lee
VOLUME 6 NUMBER 1 JUNE 2017 23
Original Article
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... Advances in technology enabled the delivery of pulsed-type RF, which produces thermal and nonthermal effects through gated RF oscillations, in contrast to continuous-type RF that produces thermal ablative effects by continuous delivery of high-frequency energy over set conduction times [6,8]. Its thermal and nonthermal effects, together with deeper tissue penetration, have led to the use of pulsed-type microneedling RF in the treatment of refractory melasma [9,10]. Proposed theories behind the observed improvement of melasma were enhanced permeability to topical treatments, and dermal effects ranging from changes in lesion vasculature and melanin washout [9], to neocollagenesis and repair of damaged basement membranes [10]. ...
... Its thermal and nonthermal effects, together with deeper tissue penetration, have led to the use of pulsed-type microneedling RF in the treatment of refractory melasma [9,10]. Proposed theories behind the observed improvement of melasma were enhanced permeability to topical treatments, and dermal effects ranging from changes in lesion vasculature and melanin washout [9], to neocollagenesis and repair of damaged basement membranes [10]. Studies that followed attributed RF's efficacy to the observed loosening of melanocyte-keratinocyte attachments, promoting transdermal melanin elimination [11], and thermo-modulated shrinkage of CD31-positive blood vessels with decreased VEGF-A mRNA expression [8]. ...
... Improved skin roughness in the current study was also observed in melasma studies utilizing microneedling RF as monotherapy [10] and in combination with Q-switched Nd:YAG (QSNY) laser toning [9,13,28]. Improved skin texture and tone was observed after 5-10 treatments at 2-3-week intervals with microneedling RF alone [10]. ...
Article
Full-text available
Introduction: This split-face, double-blind, randomized controlled study investigated the efficacy and safety of using a microneedling radiofrequency (RF) device with polynucleotides (PN) versus RF alone for the treatment of melasma. Methods: Thirty adult participants with melasma (Fitzpatrick skin types III-V) received three treatments with an invasive, bipolar, pulsed-type microneedling RF device on both sides of the face. The treatment sessions occurred once every 2 weeks. The hemifaces of each participant were designated for treatment and control with PN and normal saline solution (NSS), applied after treatment with RF. Measurements were made of melanin index (MI), erythema index (EI), skin roughness (by the Antera 3D system), modified melasma area severity index (mMASI) for each hemiface, and patients' self-assessed improvement. These occurred at baseline and again following the final treatment (2 weeks and 1, 2, 3, and 6 months after). Mean values were obtained for MI, EI, skin roughness, and mMASI. A generalized estimating equation (GEE) was used to compare the obtained values for the outcome measures across all assessment points. Results: All patients were women (mean age, 43.2 ± 7.0 years). Mixed melasma predominated (61.5%; n = 16), and the mean duration of melasma was 8.9 ± 6.5 years. Twenty-six participants were followed up to the 6-month assessment point. Significant improvements were observed from baseline in MI, skin roughness, and mMASI scores for both the PN and control sides at 6 months, with no statistically significant differences between sides. Patients' self-assessed improvement scores also showed a positive trend. Melasma recurrence was observed in three patients at 2, 3, and 4 months after the last treatment session (10% recurrence rate). Conclusions: The combination of an invasive, bipolar, pulsed-type microneedling RF with PN is not superior compared with microneedling RF alone in the treatment of melasma. Microneedling RF may be considered as safe and efficacious for the improvement of skin roughness, and as an adjunctive treatment option for melasma. Clinical trial registration: This study was registered on ClinicalTrials.gov and assigned NCT number TCTR20210804002.
... Microneedle RF, known for minimal epidermal ablation, proves effective in skin rejuvenation and holds potential for treating melasma by enhancing the impaired ECM and promoting melanin elimination 91,92 . Recent research suggests that pulsed-type microneedling RF could be effectively employed for refractory melasma due to its effects, including enhanced permeability for topical treatments and induction of various dermal changes such as alterations in vasculature, melanin washout, and neocollagenesis 93,94 . ...
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Melasma is a prevalent hyperpigmentation condition known for its challenging treatment due to its resemblance to photoaged skin disorders. Numerous studies have shed light on the intricate nature of melasma, which often bears similarity to photoaging disorders. Various therapeutic approaches, encompassing topical and systemic treatments, chemical peeling, and laser therapy, have exhibited efficacy in managing melasma in previous research. However, melasma often reoccurs despite successful treatment, primarily due to its inherent photoaged properties. Given that melasma shares features with photoaging disorders, including disruptions in the basement membrane, solar elastosis, angiogenesis, and mast cell infiltration in the dermal layer, a comprehensive treatment strategy is imperative. Such an approach might involve addressing epidermal hyperpigmentation while concurrently restoring dermal components. In this article, we provide a comprehensive review of conventional treatment methods frequently employed in clinical practice, as well as innovative treatments currently under development for melasma management. Additionally, we offer an extensive overview of the pathogenesis of melasma.
... But most of the treatment modalities have side effects, so other treatment options are needed. Radiofrequency (RF) irradiation with micro-invasive electrodes is effective for improving pigmentation disorders, thickening the basement membrane, providing vascular modulation, and increasing dermal collagen production [22,23]. One study has shown the effectiveness of RF irradiation for the treatment of skin inflammation, but only a few studies have explored the mechanism of RF's effects on skin [24]. ...
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Melasma is a common acquired hyperpigmentary skin disorder characterized by light to dark brown macules and patches occurring in the sun-exposed areas of the face. Melasma lesional skin is characterized by epidermal hyperpigmentation through increased melanogenesis in epidermal melanocytes. Some patients have dermal melanin but its amount is not significant and its distribution is very heterogeneous in the whole melasma lesional skin. Melasma is not homogeneous disease and there are personal characteristics of patients with melasma. The pathogenesis of melasma is not fully understood, but several hypotheses have been suggested. Increased vascularity in melasma lesions has suggested the role of increased number of enlarged vessels in the development of melasma. Endogeneous and exogeneous stimuli such as sex hormones and ultraviolet irradiation respectively may stimulate the microenvironment leading to the release of various mediators that cause activation of melanocytes and/or these stimuli may directly activate the melanocytes. Melasma patients may have specialized melanocytes with an intrinsic sensitivity to these stimuli.
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Background: Laser treatment in melasma has previously failed because of the resulting inflammation and consequent pigmentation and excessive thermal damage caused by the use of high fluence. Objective: This study is aimed at establishing the concept of the collimated low fluence Q-switched Nd : YAG laser as a treatment for melasma by investigating its therapeutic effects clinically as well as histopathologically. Methods: 27 patients were treated weekly with Q-switched Nd : YAG laser (1,064 nm wavelength, 7 mm spot size, 1.6-2.5 J/cm2 fluence) for 8 weeks. The results were evaluated based on standardized clinical images that used Robo skin analyzer, spectrophotometer, MASI score and general severity. Results: 17 (58.8%) patients showed "GOOD" (50-75% improvement) and no case of full recurrence was examined and partial recurrence was detected in 12/17 patients. Common adverse effects include pain, erythema, and temporary edema. Rarely partial hypopigmented macules and diffuse hyperpigmentation appeared. Additional studies, such as immunohistochemical examination and electron microscopic examination, are also currently in progress. Conclusion: The collimated low fluence Q-switched Nd : YAG Laser is effective in melasma treatment. This treatment method is a new concept that can be described as selective photothermolysis with minimal thermal damage and inflammation reaction to affected tissues by pigmentation. We consider this treatment method should be regarded as Minimized Selective Photothermolysis (MSP) that will provide a new effective treatment for melasma.
Article
Due to the transepidermal potential of 15-50 mV, inside positive, an injury current is driven out of all human skin wounds. The flow of this current generates a lateral electric field within the epidermis that is more negative at the wound edge than at regions more lateral from the wound edge. Electric fields in this region could be as large as 40 mV/mm, and electric fields of this magnitude have been shown to stimulate human keratinocyte migration toward the wounded region. After flowing out of the wound, the current returns through the space between the epidermis and stratum corneum, generating a lateral field above the epidermis in the opposite direction. Here, we report the results from the first clinical trial designed to measure this lateral electric field adjacent to human skin wounds noninvasively. Using a new instrument, the Dermacorder®, we found that the mean lateral electric field in the space between the epidermis and stratum corneum adjacent to a lancet wound in 18-25-year-olds is 107-148 mV/mm, 48% larger on average than that in 65-80-year-olds. We also conducted extensive measurements of the lateral electric field adjacent to mouse wounds as they healed and compared this field with histological sections through the wound to determine the correlation between the electric field and the rate of epithelial wound closure. Immediately after wounding, the average lateral electric field was 122 ± 9 mV/mm. When the wound is filled in with a thick, disorganized epidermal layer, the mean field falls to 79 ± 4 mV/mm. Once this epidermis forms a compact structure with only three cell layers, the mean field is 59 ± 5 mV/mm. Thus, the peak-to-peak spatial variation in surface potential is largest in fresh wounds and slowly declines as the wound closes. The rate of wound healing is slightly greater when wounds are kept moist as expected, but we could find no correlation between the amplitude of the electric field and the rate of wound healing.
Article
A number of electromagnetic field-based technologies are available for therapeutic medical applications. These therapies can be broken down into different categories based on technical parameters employed and type of clinical application. Pulsed radio frequency energy (PRFE) therapy is a non invasive, electromagnetic field-based therapeutic that is based on delivery of pulsed, shortwave radio frequency energy in the 13-27.12 MHz carrier frequency range, and designed for local application to a target tissue without the intended generation of deep heat. It has been studied for use in a number of clinical applications, including as a palliative treatment for both postoperative and non postoperative pain and edema, as well as in wound healing applications. This review provides an introduction to the therapy, a summary of clinical efficacy studies using the therapy in specific applications, and an overview of treatment-related safety.
Article
The efficacy of a 1064-nm Q-switched neodymium:yttrium-aluminium-garnet (QS Nd:YAG) laser with low pulse energy in the treatment of melasma in 25 women was assessed by retrospective analysis of clinical photographs and patient satisfaction rates. Follow-up results 2 months after the last treatment revealed that, as defined by our grading scale, 11 of the 25 patients (44%) had marked clinical improvement: 7 of these (28%) had near-total clinical improvement, 5 had moderate clinical improvement and 2 had minimal to no improvement. Our data suggest that the use of a QS Nd:YAG laser with low pulse energy is an effective, easily performed treatment for melasma in selected East Asian patients.
Article
Melasma is a common hyperpigmentation disorder that can cause refractory cosmetic disfigurement, especially in Asians. Fractional photothermolysis (FP) has been reported to be effective for the treatment of melasma, despite small study populations and short follow-up periods. To evaluate the efficacy and safety of FP for the treatment of melasma in Asians. Twenty-five patients with melasma received four monthly FP sessions and were followed up to 24 weeks after treatment completion. Efficacy was evaluated using objective and subjective ratings, Melasma Area and Severity Index (MASI), melanin index tracking, and skin elasticity measurements. Investigators observed clinical improvements in 60% and patients in 44% at 4 weeks after treatment, but the figures decreased to 52% and 35%, respectively, at 24 weeks after treatment. Mean MASI scores decreased significantly from 7.6 to 6.2. Mean melanin index decreased significantly after the first two sessions, but it relapsed slightly in subsequent follow-ups. The treatment did not alter skin elasticity. Hyperpigmentation was observed in three of 23 subjects (13%). Treatment of melasma with FP led to some clinical improvements, but it was not as efficacious as previously reported at 6-month follow-up. We recommend judicious use of FP for the treatment of melasma in Asian skin because of its limited efficacy.