Pigmentary problems: Combination therapies, fractional lasers keep melasma at bay

June 1, 2008

Between lasers, chemical peels and topicals, dermatologists have an ever-expanding armament for combating sun-related pigmentary problems, and they are continuing to tweak treatment combinations to come up with the best results for specific pigmentary problems.

Key Points

Melasma has been particularly frustrating for physicians, and some report that even newer fractional lasers, which offer good results in other areas such as photodamage and acne scars, have inconsistent results when it comes to melasma. However, recent research shows impressive results with various chemical peel and topical approaches.

One study, looking at a combination of a trichloroacetic acid (TCA) peel with topical 5 percent ascorbic acid, found a greater decrease in melasma compared to a TCA peel alone (JCosmet Dermatol. 2007 Jun;6(2):89-94).

In that study, 20 female patients were given a series of five glycolic acid peels beginning two weeks after starting daily cream applications, which consist of a stable combination of fluocinolone acetonide 0.01 percent, hydroquinone 4 percent and tretinoin 0.05 percent.

The results show a 40 percent mean improvement in hyperpigmentation after six weeks, and the mean improvement was an impressive 80 percent after eight weeks.

Side effects were reported to be mild, and included erythema, scaling, dryness, stinging/burning, edema and telangiectasias.

Tri-Luma effective

Joel Schlessinger, M.D., says he has also had success with triple-combination cream product Tri-Luma (Galderma), particularly for discrete areas of melasma; in severe cases of melasma, he often turns to a combination of the Obagi skincare regimen and Retin-A.

"We try to place all our patients with moderate to severe melasma on (that combination), and it amazes me to see how many patients will have a 'laser-like' response to this regimen," says Dr. Schlessinger, director of the Advanced Skin Research Center in Omaha, Neb.

Dr. Schlessinger says he has also had success with the LHA (lipohydroxy acid) peel and the newer SilkPeel.

"These peels allow for options and alternating treatments for patients who may have started out with microdermabrasion and now are looking for different, newer treatments," he says.

Hands and face

For both the hands and face, peels offer a variety of choices to suit patients' individual needs, and still hold an important place for correcting pigmentary problems, despite stiff competition from state-of-the-art lasers.

"There is still a use for chemical peels, and my guess is that they will continue to be popular," Dr. Schlessinger tells Dermatology Times.

Physicians who do take the laser route report exceptionally impressive results with fractional resurfacing for pigmentary problems on the hands. Lasers such as Fraxel (Reliant Technologies) have been shown to address dyschromias and rhytids on the face, and a recent small study in 10 patients indicates that the results can translate to the hands as well.

Subjective assessments of skin roughness, wrinkling and pigmentation on a five-point scale at one and three months showed a mean 51 percent to 75 percent improvement in skin pigmentation and 25 percent to 50 percent improvement in skin roughness and wrinkling.

Furthermore, biopsies showed increased density of dermal collagen (Dermatol Surg. 2008 Jan;34(1):73-78. Epub 2007 Dec 5).

Dr. Schlessinger says his practice uses Fraxel as well as StarLux (Palomar) lasers on the hands, but patients also appreciate chemical peels for those purposes.

"The hands are clearly one of those areas that trouble people as they age, and these newer treatments are capturing the imagination of many of our patients," he says.

On the milder end of laser treatments, intense pulsed light may not always hit a home run, but has the big benefit of minimal downtime, Dr. Schlessinger says.

"Patient friendly" are the operative words, Dr. Schlessinger says, because regardless of the treatment regimen, combating pigmentary problems will likely require a lifelong commitment.