ThuliumV1, Pmc, Corpus, bibRecord, 000201

Lasers are not Effective for Melasma in Darkly Pigmented Skin

Identifieur interne : 000201 ( Pmc/Corpus ); précédent : 000200; suivant : 000202

Lasers are not Effective for Melasma in Darkly Pigmented Skin

Auteurs : Kabir Sardana ; Vijay K. Garg

Source :

Journal of Cutaneous and Aesthetic Surgery [ 0974-2077 ] ; 2014.

RBID : PMC:3996796
Url:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3996796

DOI: 10.4103/0974-2077.129985
PubMed: 24761105
PubMed Central: 3996796

Links to Exploration step

PMC:3996796

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<author><name sortKey="Sardana, Kabir" sort="Sardana, Kabir" uniqKey="Sardana K" first="Kabir" last="Sardana">Kabir Sardana</name>
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<author><name sortKey="Garg, Vijay K" sort="Garg, Vijay K" uniqKey="Garg V" first="Vijay K" last="Garg">Vijay K. Garg</name>
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<pmc article-type="letter"><pmc-dir>properties open_access</pmc-dir>
  <front><journal-meta><journal-id journal-id-type="nlm-ta">J Cutan Aesthet Surg</journal-id>
<journal-id journal-id-type="iso-abbrev">J Cutan Aesthet Surg</journal-id>
<journal-id journal-id-type="publisher-id">JCAS</journal-id>
<journal-title-group><journal-title>Journal of Cutaneous and Aesthetic Surgery</journal-title>
</journal-title-group>
<issn pub-type="ppub">0974-2077</issn>
<issn pub-type="epub">0974-5157</issn>
<publisher><publisher-name>Medknow Publications & Media Pvt Ltd</publisher-name>
<publisher-loc>India</publisher-loc>
</publisher>
</journal-meta>
<article-meta><article-id pub-id-type="pmid">24761105</article-id>
<article-id pub-id-type="pmc">3996796</article-id>
<article-id pub-id-type="publisher-id">JCAS-7-57</article-id>
<article-id pub-id-type="doi">10.4103/0974-2077.129985</article-id>
<article-categories><subj-group subj-group-type="heading"><subject>Letters</subject>
</subj-group>
</article-categories>
<title-group><article-title>Lasers are not Effective for Melasma in Darkly Pigmented Skin</article-title>
</title-group>
<contrib-group><contrib contrib-type="author"><name><surname>Sardana</surname>
<given-names>Kabir</given-names>
</name>
<xref ref-type="aff" rid="aff1"></xref>
</contrib>
<contrib contrib-type="author"><name><surname>Garg</surname>
<given-names>Vijay K</given-names>
</name>
<xref ref-type="aff" rid="aff1"></xref>
</contrib>
</contrib-group>
<aff id="aff1"><italic>Department of Dermatology, Maulana Azad Medical College and Lok Nayak Hospital, Delhi, India E-mail:<email xlink:href="kabirijdvl@gmail.com">kabirijdvl@gmail.com</email>
</italic>
</aff>
<pub-date pub-type="ppub"><season>Jan-Mar</season>
<year>2014</year>
</pub-date>
<volume>7</volume>
<issue>1</issue>
<fpage>57</fpage>
<lpage>60</lpage>
<permissions><copyright-statement>Copyright: © Journal of Cutaneous and Aesthetic Surgery</copyright-statement>
<copyright-year>2014</copyright-year>
<license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by-nc-sa/3.0"><license-p>This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.</license-p>
</license>
</permissions>
</article-meta>
</front>
<body><p>Sir,</p>
<p>We read with interest the study of Puri <italic>et al</italic>
.,[<xref rid="ref1" ref-type="bibr">1</xref>
] and we would like to point out certain facts, coupled with our experience regarding the use of lasers in melasma.[<xref rid="ref2" ref-type="bibr">2</xref>
<xref rid="ref3" ref-type="bibr">3</xref>
<xref rid="ref4" ref-type="bibr">4</xref>
] This is relevant as recent expert reviews[<xref rid="ref4" ref-type="bibr">4</xref>
<xref rid="ref5" ref-type="bibr">5</xref>
] have cast a doubt on the use of lasers in melasma.</p>
<p>The variation in results due to the use of the subjective MASI scores in favour of the better and objective Mexameter reading assessment is crucial to interpretation of results.[<xref rid="ref3" ref-type="bibr">3</xref>
] The evaluation using MASI even by clinical photographs is not reliable, which is mirrored by the images depicted in the study, and do not depict the profound improvement noted by the authors.[<xref rid="ref1" ref-type="bibr">1</xref>
] Also the pigment in the epidermis alters the laser physics dynamics specially in pigmented skin accounting for the variable results.[<xref rid="ref2" ref-type="bibr">2</xref>
] The pigment in melasma is not homogeneous either in distribution or depth[<xref rid="ref3" ref-type="bibr">3</xref>
] and it is difficult to understand how the authors ensured that the two groups had a similar type of melasma (epidermal/dermal or mixed). It would also have been informative to know at which sitting the improvement in melasma was noted. Also the duration of melasma prior to initiation of treatment is a determinant in results in melasma, which is not mentioned in the study. A more crucial and relevant aspect is seasonal variation, which has been highlighted by a previous study[<xref rid="ref3" ref-type="bibr">3</xref>
] wherein to account for the spontaneous improvement of melasma that is usually observed during autumn and winter months, all the patients were included at the end of winter season and a final visit was scheduled after the summer, at least 2 months after the last treatment in melasma. Thus probably a split-face trial design is ideal for meaningful melasma studies.</p>
<p>All the lasers tried for melasma, including the pigment-specific lasers (Q-switched, long-pulsed lasers and IPL), ablative lasers (Er: YAG) and fractional lasers have had indifferent results [<xref ref-type="table" rid="T1">Table 1</xref>
]. Transient results have been seen for the epidermal subtype, but dermal melasma and the mixed type, which constitute the majority of patients in pigmented skin are difficult to treat.[<xref rid="ref6" ref-type="bibr">6</xref>
<xref rid="ref7" ref-type="bibr">7</xref>
] “Laser toning” involves the use of large spot size, and a low-fluence, QS 1064-nm Nd: YAG laser (6- to 8-mm spot size, 1.6-2.3 J/cm<sup>2</sup>
) requires a fairer skin types,[<xref rid="ref7" ref-type="bibr">7</xref>
] a large spot size and can lead to mottled de-pigmentation.</p>
<table-wrap id="T1" position="float"><label>Table 1</label>
<caption><p>Chronological Summary of the salient work on Lasers and their combinations in Melasma</p>
</caption>
<graphic xlink:href="JCAS-7-57-g001"></graphic>
</table-wrap>
<p>Though peels have been touted as an useful intervention it is a universal “practical” experience that without triple combination (TC) creams the results are not great, especially in pigmented skin. This is probably as deep peels (papillary dermis level), which are useful in the common mixed dermal melasma cases, are difficult to use in pigmented skin due to their potential for PIH. Hurley <italic>et al</italic>
.,[<xref rid="ref8" ref-type="bibr">8</xref>
] conducted the first randomised, investigator-blinded, controlled, split-faced study and compared the use of hydroquinone (HQ) alone with HQ plus Glycolic acid (GA) peels in a homogeneous (Hispanic) population using objective (photography, mexameter readings and MASI) and subjective measures. The authors found that though the combination of GA and HQ improved melasma, there were <italic>no significant</italic>
 differences in skin lightening between regimens. This highly accessed article (2266 times!) in conjunction with another study[<xref rid="ref9" ref-type="bibr">9</xref>
] with similar findings have brought forth the evident fact that probably the results of 4% HQ are better than the chemical peels used. Thus logically a TC cream would have superior results to the chemical peel! This is highlighted by the studies where TC have been combined and compared with lasers and have been found to have superior results,[<xref rid="ref10" ref-type="bibr">10</xref>
<xref rid="ref11" ref-type="bibr">11</xref>
<xref rid="ref12" ref-type="bibr">12</xref>
] which probably puts a question mark on the unnecessary use of lasers in melasma.</p>
<p>The principles of laser therapy involve a pertinent target (melanocytes in melasma), appropriate wavelength and the right pulse duration. The fractional lasers are selective for water and their pulse duration is in milliseconds unlike the microsecond thermal relaxation time (TRT) of melanocyte making them intrinsically inappropriate in melasma. This coupled with the fact that only a “fraction” of the skin is damaged, makes the technology inherently ineffective for melasma [<xref ref-type="fig" rid="F1">Figure 1</xref>
]. Fractionated laser treatment may work by expelling columns of microscopic epidermal debris that contains melanin but is probably insufficient to make a clinical difference.[<xref rid="ref4" ref-type="bibr">4</xref>
<xref rid="ref5" ref-type="bibr">5</xref>
<xref rid="ref6" ref-type="bibr">6</xref>
<xref rid="ref7" ref-type="bibr">7</xref>
] Melasma has a high risk of recurrence with fractional laser therapy[<xref rid="ref7" ref-type="bibr">7</xref>
] and the relative high rate of re-pigmentation and sometimes even an increase in pigmentation after the treatment makes it a risky option.[<xref rid="ref7" ref-type="bibr">7</xref>
<xref rid="ref13" ref-type="bibr">13</xref>
]</p>
<fig id="F1" position="float"><label>Figure 1</label>
<caption><p>A pictoral depiction of the effect of fractional lasers in Melasma</p>
</caption>
<graphic xlink:href="JCAS-7-57-g002"></graphic>
</fig>
<p>Our experience with patients of melasma using various lasers, such as the IPL (3), Qsw Nd: YAG (2), fractional Er: Yag (7) and ablative Er:YAG (2 cases), mirror the fact that the results in melasma are transient with rapid recurrence [<xref ref-type="fig" rid="F2">Figure 2</xref>
]. In fact with the fractional lasers, a rebound hyperpigmentation has been noted in our analysis, which is similar to the results noted by Karsai <italic>et al</italic>
.,[<xref rid="ref13" ref-type="bibr">13</xref>
]</p>
<fig id="F2" position="float"><label>Figure 2</label>
<caption><p>A retrospective overview of Lasers used in Melasma (2007–2013) Improvement/Worsening (0–25%; 1: 26–50%; 2: 51–75%; 3: 76% >; 4). The maximum improvement attained (26–50%) by the QswNd: YAg, Fractional Er: YAg, Fractional CO<sup>2</sup>
 and Er: YAG (Erbium Peel) was followed by a deterioration 2 months after the last sitting. This post inflammatory pigmentation (PIH) subsided after a mean of 3.2 months</p>
</caption>
<graphic xlink:href="JCAS-7-57-g003"></graphic>
</fig>
<p>Two recent reviews[<xref rid="ref4" ref-type="bibr">4</xref>
<xref rid="ref5" ref-type="bibr">5</xref>
] aptly summarise the present evidence on melasma. The use of lasers for the treatment of melasma cannot be recommended as a first line treatment of melasma due to their unpredictable efficacy and safety.[<xref rid="ref10" ref-type="bibr">10</xref>
<xref rid="ref11" ref-type="bibr">11</xref>
<xref rid="ref12" ref-type="bibr">12</xref>
<xref rid="ref13" ref-type="bibr">13</xref>
<xref rid="ref14" ref-type="bibr">14</xref>
<xref rid="ref15" ref-type="bibr">15</xref>
<xref rid="ref16" ref-type="bibr">16</xref>
<xref rid="ref17" ref-type="bibr">17</xref>
<xref rid="ref18" ref-type="bibr">18</xref>
<xref rid="ref19" ref-type="bibr">19</xref>
<xref rid="ref20" ref-type="bibr">20</xref>
<xref rid="ref21" ref-type="bibr">21</xref>
<xref rid="ref22" ref-type="bibr">22</xref>
<xref rid="ref23" ref-type="bibr">23</xref>
<xref rid="ref24" ref-type="bibr">24</xref>
] They can be considered as third line treatment when all other modalities have failed and patient wishes to try alternative treatment. Such treatments are not curative and should be made clear to patients when such treatments are offered to the patient. Patients should be informed of their high chance of recurrence upon stopping treatment and risk of complications.[<xref rid="ref5" ref-type="bibr">5</xref>
] Combination therapies including TC are probably more effective.[<xref rid="ref4" ref-type="bibr">4</xref>
] Thus probably melasma is nature's way to compensate for the high ambient ultraviolet flux in tropical countries and any method to remove it would probably lead to indifferent results and rapid recurrence. Though we have no experience in treating fair skin types, in our skin type, lasers should not be the preferred treatment for melasma.</p>
</body>
<back><ref-list><title>REFERENCES</title>
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Lasers are not Effective for Melasma in Darkly Pigmented Skin

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