Role of laser therapy
Dr. Levine: Is there any role for lasers in the treatment of melasma?
Dr. Desai: Yes, I do laser therapy. Ideally the one that I use is the Q-switched Nd:YAG. The reason is the frequency and the pulse duration: The Q-switched is a much faster treatment in terms of its pulse duration. Again, I pretreat with hydroquinone, lightening agent, and sunscreen prior to the treatment and perform three to four sessions spaced apart monthly. There are some good studies supporting this, too.[iv]
I will also perform laser treatments on patients with skin of color; however, one has to have a really motivated patient. I would not do laser first-line prior to peel. Unless the patient is absolutely adamant, I start with the peels. If the peels don’t have good results, I move up to the next treatment option, which could be laser therapy, higher strength hydroquinone, non-hydroquinone based lightening agents, or other modalities.
Dr. Levine: If a person comes in who clearly has a major risk for continued melasma — they are on birth control pills, they are pregnant, etc. — will you try to treat them aggressively in the face of having the risk factor?
Dr. Desai: This issue comes up a lot. I do treat women who have had one pregnancy and who are postpartum, then develop melasma, but still plan on additional pregnancies. I have the discussion with them about the etiology and root cause of what is most likely causing the condition. Studies in the past five to six years have found that there are triggers for melasma, are primarily hormonal in many cases, but it’s more of a multifactorial condition than we realize. So it’s probably not just the hormonal influence that’s triggering the condition to perpetuate. It’s probably triggering the onset.
We know melasma can be epidermal, dermal or mixed, and the long-term problem if melasma continues untreated is that pigmentation is going to go deeper into the dermis where you are going to get a lot of pigment incontinence. Once you get that dermal pigment or that mixed pathology melasma (that) you see on biopsy, it’s virtually impossible to get rid of that dermal pigment. So treating it aggressively early on when you mostly have epidermal involvement is key.
This brings me to one other point, which is biopsy. If I have a patient who comes in who is not responding to therapy, I consider alternatives to melasma. I think there is a gut instinct to put patients with facial hyperpigmentation in the melasma box, but it’s not always the case. A small 2mm punch biopsy from the lateral part of the face, such as the lateral zygoma, actually heals very well with minimal scarring. The biopsy is going to give you a lot of insight into what treatments you can tailor for that patient.
So I do encourage my colleagues to think about that if (they) have a patient who is not responding to therapy or has somewhat of an atypical presentation.