With summer upon us, patients will spend more time outdoors doing the things they love to do.
While having fun, most people do not think about the effects of the sun upon the skin.
Sun exposure will either cause or exacerbate problems of pigmentation.
One of the most common concerns patients present are disorders of hyperpigmentation.
Increased pigmentation can be the result of many things, ranging from hormonal issues to sun exposure and the use of some medications.
In order to help our patients, it is incumbent upon us to evaluate the precipitating factors and tailor a treatment that will best fit the particular type of hyperpigmentation and the lifestyle of the patient.
This is an exciting time to be practicing medicine, as there are many devices and medications we can employ.
“MASK OF PREGNANCY”
Melasma—also known as chloasma or the “mask of pregnancy”—is a dark skin discoloration found on sun-exposed areas of the face. It is often associated with the female hormones estrogen and progesterone, and it is especially common in pregnant women, women who are taking oral contraceptives, and women who are taking hormone-replacement therapy during menopause.
One of the most common problems of pigmentation, melasma involves a process in which a select group of melanocytes work overtime to produce excess melanin.
It is thought that estrogen can stimulate the production of melanin.
However, it also can be seen in patients who are not pregnant or on the pill. Rarely, it is seen in men.
Most patients are anxious to achieve a quick fix, which, unfortunately, does not exist.
Last summer, I saw a young Asian woman who was tanned and had obvious melasma.
She had been seen at a local medical spa, where she was told she needed $5,000 worth of laser treatments, after which she would see rapid results.
I had a hard time convincing her that she would be better served with a high-SPF-rated sunscreen and Galderma Laboratories’ Tri-Luma Cream.
Tri-Luma Cream is a compound of hydroquinone, tretinoin, and a topical steroid.
I have found the results superior to products that contain only hydroquinone.
Treating a tanned Asian patient with a laser- or light-based device could have led to a disastrous result.
The FDA approved Tri-Luma Cream as the only triple-action cream used for the short-term and intermittent long-term treatment of moderate to severe melasma.
Prior to this, many dermatologists prescribed a similar cream known as Kligman’s Formula, which needed to be compounded at the pharmacy.
Although my practice uses a Reliant Technologies Fraxel laser, I did not prescribe a series of laser-based treatments for this patient, which could have cost several thousand dollars.
Instead, I prescribed a cream that cost the patient approximately $100.
Reluctantly, she went along with the plan. After 8 weeks, she showed a 90% improvement.
Unfortunately, not all patients with melasma have this kind of positive response.
For example, some patients will not see improvement if they continue to take oral contraceptives.
Some patients lost pigment in their face and their skin became a shade lighter after laser treatment.
Many patients are reluctant to choose an alternative form of birth control, or must continue on oral contraceptives for medical reasons.
The first step in treating patients with stubborn melasma is to have them discontinue the use of birth-control pills.
For patients with stubborn melasma, I might try laser-based or intense pulsed light (IPL) treatment.
In darker-skinned patients, a test spot treatment can avoid hypopigmentation or depigmentation.
Each new laser that hits the marketplace seems to make claim of how well it can treat melasma.
Usually, the results do not live up to the hype.
Some patients will respond to light peels with glycolic acid or with a low concentration of trichloroacetic acid.
Tri-Luma Cream is FDA-approved for the short-term and intermittent long-term treatment of moderate to severe melasma.
For those who do respond to peels. I use either an IPL-based treatment or try Reliant’s Fraxel Re:store laser system.
Results from either approach have been mixed, with some patients showing significant improvement and others showing some darkening.
Melasma involves a dynamic process, with increased melanin production. The other type of hyperpigmentation, such as what can be seen in patients with chronic sun damage, is more of a static process that tends to be easier to treat.
For patients who have only a few lentigines, spot treatment is the way to go.
Patients with sun-damaged skin tend to develop multiple lentigines or what many people refer to as “liver spots.”
In addition, these patients develop a diffuse brownish discoloration of sun-exposed areas. as well as poikiloderma—a combination of hyperpigmentation and a proliferation of small blood vessels known as telangiectasia.
We utilize either a Q-switched alexandrite laser (755 nm) or a double-frequency Nd:YAG laser.
Patients with sun-damaged skin tend to develop multiple lentigines or “liver spots.”
Typically, the spots that are treated get crusty for about 1 week.
Most patients will see a 70% to 80% improvement with one treatment.
In darker-skinned patients, I often perform a test spot to find the optimal energy setting that will not cause hypopigmentation or depigmentation.
Even if you do not have laser- or light-based devices available in your practice, you can treat these spots with cryosurgery.
However, you must be careful not to overtreat, as melanocytes are extremely sensitive to cold and there is the risk of permanent depigmentation.
A 35-year-old Asian woman treated with a combination of IPL, Q-switched laser, and Tri-Luma for photodamage and postinflammatory hyperpigmentation.
Some patients have so many spots—as well as more diffuse hyperpigmentation—that spot treatment would be impractical and a suboptimal solution.
The most common form of hyperpigmentation I see in my practice is a mixed presentation of relatively fair-skinned patients with chronically sun-damaged skin.
The skin will often show distinct lentigines, diffuse hyperpigmented patches, fine telangiectasia, and varying degrees of rhytids.
With the myriad of devices available to treat these conditions, one can create a customized treatment for each patient.
We treat many active, busy professionals who cannot tolerate any downtime.
Usually, I will treat these patients with IPL-based devices.
The typical approach involves five treatments with 3 weeks between treatments.
IPL-based devices differ from lasers in that instead of a single wavelength of light being utilized, filters of different wavelengths are employed and a broader spectrum of light is emitted.
The light energy is absorbed by the targets, such as pigment and blood vessels, and the light energy is converted to heat energy, resulting in destruction of the target.
IPL works well for treating large surface areas in a relatively quick fashion and can be used almost anywhere on the body.
There is some nonspecific absorption that can result in collagen remodeling.
Some lucky patients will see some improvement in fine lines, but this is unpredictable.
I do not promote IPL-based treatment for fine lines.
Most people can return to normal activities the day after their treatment.
If one thinks of the patient’s skin as a canvas upon which we are working, then IPL can improve the color but achieves only minimal improvement for skin texture.
For patients who are severely sun damaged and have early precancerous changes, I might combine an IPL-based treatment with Levulan Blue Light, which is a type of photodynamic therapy (PDT) that consists of the topical application of Levulan (aminolevulinic acid) combined with BLU-U, a specialized blue light treatment.
With PDT, I will see an improvement in the color and texture of the patient’s skin.
However, this approach adds downtime for patients, as they are usually quite red and somewhat crusty for 5 to 10 days.
In addition, as the Levulan takes about 2 days to be cleared from the skin, patients must obey strict sun avoidance.
Fractional resurfacing has become one of the newest, more exciting advances in laser technology.
Compared with traditional laser resurfacing, which treats the entire skin surface, fractional laser devices target small microscopic treatment zones, sparing the surrounding skin.
The laser delivers a series of microscopic, closely spaced laser spots to the skin while simultaneously preserving the healthy skin between, resulting in rapid healing following treatment.
Fractional lasers strive to achieve the skin improvements obtained with ablative lasers but without the associated side effects or downtime.
Reliant’s Fraxel Re:store Erbium-doped laser fractionally heats the skin, resulting in improvement in color and texture of skin.
There is minimal downtime—most patients are back to work within 2 days.
The most common side effect is swelling. Most patients require four to six treatments spaced about a month apart.
In the wake of the success of the re:store laser system, other manufactures have begun to employ similar fractionated devices.
Fractionated CO2-based lasers are the newest kids on the block for treating hyperpigmentation associated with photodamage.
Perhaps the biggest drawback to traditional CO2-based lasers was that they really did not work well “off the face.”
Some patients actually lost pigment in their face, and their facial skin became a shade lighter.
Others showed a noticeable line of demarcation from the face to the neck.
The new fractional CO2 lasers can be employed on or off the face.
One can adjust the fluency, which determines the depth of penetration as well as the percentage of coverage.
Typically, I use higher settings on the face for both depth of penetration and percent coverage.
As with many devices, I see more dramatic results at the higher settings.
In contrast to IPL and other nonablative treatments requiring multiple sessions, I schedule patients to receive one or two fractional CO2 treatments.
Initially, I treat the patient with nerve blocks and a topical anesthetic cream.
However, I find that patients are much more comfortable with tumescent local anesthesia of the face.
As most patients seeking this treatment hope to see maximal results quickly, there is some downtime.
For instance, many patients see pin-point bleeding spots for approximately 2 to 3 days; most are fully reepithialized by day 3.
It then takes about 10 to 14 days for swelling to subside.
A slight pinkness to the skin is present at 4 weeks, but is minimal compared with what one would see with traditional CO2-based laser resurfacing.
As we age, there are several things that can make us look older, including sagging skin, loss of volume and color, and textural changes of the skin.
It is important that we look at the patient as whole and address all of these concerns.
Currently, we have a wide range of treatment options for pigmentation.
Prevention and education always comes first.
In addition to all the treatment options, I recommend that patients avoid the peak sun hours and use sunscreen on a daily basis.
This approach will ensure that patients will minimize the problems of hyperpigmentation and yield the best possible result.
by Jerome Potozkin, MD