peer-review | Dermatology |

Lasers for
hyperpigmentation
and melasma
Paolo Bonan, Andrea Bassi, Michela Troiano, Nicola Bruscino,
Rossana Conti, Cristiano Morini, Giovanni Cannarozzo, Silvia
Moretti, and Piero Campolmi discuss the use of a range of laser
devices to treat pigmentation disorders

acid, ellagic acid, mequinol, ascorbic acid, and

ABSTRACT resveratrol) alone or in combination with chemical peels
Melasma is one of the most commonly-acquired hypermelanosis of
skin exposed to the sun. Treatments including hypopigmenting agents
or physical treatments.
and chemical peels have been used, but at present no pharmacologic Laser devices have revolutionised the treatment of
agent has been universally recognised as effective for the treatment of many dermatological conditions, including pigmentary
melasma. Recently, the Q-switched Nd:YAG laser has been proposed.
This evaluation confirms how, by minimising side-effects, treatment disorders. They have been widely used with variable
time and costs, the Q-switched Nd:YAG laser can be effective and levels of success for the treatment of pigmented
safe for lightening cutaneous hyperpigmentation. The biological conditions such as Becker’s nevus, café au lait macules,
role of cutaneous blood vessels in the pathogenesis of melasma is
an interesting topic and opens new therapeutic perspectives. The nevus of Ota, nevocellular nevus, lentigines, tattoos,
authors recently performed a prospective study for evaluating the melasma, and post-inflammatory hyperpigmentation
effects of pulsed dye laser (PDL) therapy. After a multispectral study
for evaluating haemoglobin and melanin components, the authors are
(PIH). Although many pigmentary disorders have shown
Paolo Bonan, andrea now using this vascular laser with low-fluence and have obtained some good results with laser treatment, the efficacy and safety
Bassi, Michela Troiano, improvements. It would be tempting to think that the action of PDL on
Nicola Bruscino, Rossana
of lasers for melasma is still controversial, with most
the vascularisation might have played an important role in preventing
Conti, Cristiano Morini, relapse. By targeting vascularisation, and at least some part of the authors citing chemical peels as the most effective
Giovanni Cannarozzo, elastosis in the melasma lesions, it might be possible to decrease the treatment option.
Silvia Moretti, and Piero stimulation of melanocytes and thus reduce the incidence of relapse.
Campolmi, Division of Clinical, Laser treatment of pigmented lesions is based on the
Preventive and Oncologic theory of selective photothermolysis, which entails a

H
Dermatology, Department specific wavelength of energy delivered in a shorter
of Critical Care Medicine and
Surgery, University of Florence yperpigmentary disorders, period of time than the thermal relaxation time (τr ) of the
School of Medicine, Florence, particularly melasma and other target chromophore, meaning that the energy is restricted
Italy
forms of primary and secondary to the target, thus causing less damage to the surrounding
email: [email protected] hyperpigmentation, can cause tissue1–2. A selective window for targeting melanin lies
significant social and emotional stress between 630 nm and 1100 nm, where there is good skin
in patients. Management is often penetration and preferential absorption of melanin over
challenging owing to the limited number of successful oxyhaemoglobin3. Absorption of the melanin decreases
treatment options currently available. Different as the wavelength increases, but a longer wavelength
therapeutic methods have been used that can be allows for deeper skin penetration. Shorter wavelengths
divided into topical and cosmetic treatments (with (< 600 nm) damage pigmented cells with lower energy
Keywords
melasma, hyperpigmentation, depigmenting agents such as hydroquinone, fluencies, while longer wavelengths (> 600 nm) penetrate
laser, pulsed light methimazole, pidobenzone, tretinoin, arbutin, azelaic deeper, but need more energy to cause melanocytic

52 September 2013 | prime-journal.com

peer-review | Dermatology |

Figure 1 Pigmented blotches on the right side of the face Figure 2 Typical erythema immediately after a session of
Q-switched Nd:YAG laser (Duolite QS; DEKA Laser, Florence, Italy)

micro-areas of ablative and thermal damage

(microthermal zones; MTZ) alternated with healthy
tissue. In the treated micro-areas, controlled heat release
produces immediate tissue shrinkage and stimulates
neocollagenesis. The areas of healthy tissue between the
treated areas ensure rapid tissue repair and a drastic
reduction in recovery time and post-treatment erythema.
This exclusive emission system makes it possible to
control tissue damage while simultaneously maximising
efficacy, with repair of the damaged areas within 1 day
and the disappearance of postoperative erythema
usually within 3–4 days6–8.
Figure 3 The disappearance of the pigmented lesions
Q-switched lasers
damage4. The τr  of melanosomes ranges between 50 ns and 500 ns
with a broad melanin absorption spectrum. Q-switched
Hyperpigmentation lasers (Nd:YAG, ruby, and alexandrite) deliver pulses
The ideal aim of laser therapy is to reduce the appearance lasting nanoseconds; therefore, they selectively target
of chromatic alterations, as well as reduce the risk of melanosomes with minimal thermal diffusion.
disfiguring scars and permanent dyschromia. Laser
systems for hyperpigmentation can be divided into: Q-switched ruby
■■ Surgical lasers The QS ruby laser, with a wavelength of 694 nm, is more
■■ QS Nd:YAG (Q-switched neodymium-doped yttrium selective for melanin than the QS Nd:YAG laser (1064 nm).
aluminum garnet; 532 nm), QS ruby (694 nm), QS Theoretically, therefore, it is expected to be more effective
alexandrite (755 nm), QS Nd:YAG (1064 nm) than QS Nd:YAG, but the role of the ruby laser is
■■ Intense pulsed light (IPL; 500–1200 nm). controversial, with studies showing conflicting results. In
particular, one disadvantage is that a deeply pigmented
Surgical lasers epidermis can impede light penetration to the dermis
Surgical lasers (generally used to treat lesions such as and unwanted epidermal injury may result in
seborrheic keratosis, warts, syringomas, dyspigmentation. In general, the QS ruby laser is not
trichoepithelioma, verrucous nevi, xanthelasma, and recommended for the treatment of hyperpigmentation
rhinophyma) can also offer an important support to the disorders in darker-skinned patients (Fitzpatrick types
treatment of hyperpigmentation by inducing tissue IV–VI)9–10.
ablation with partially-selective thermal damage and a
moderate risk of scarring and dyschromia. The Er:YAG Q-switched Nd:YAG
laser emits light with a 2940 nm wavelength, which is The 532 nm QS Nd:YAG is well absorbed by melanin and
highly absorbed by water and penetrates much less than being a longer wavelength, causes minimal damage to
CO2 lasers, thus ablating the skin with only minimal the epidermis and is not absorbed by haemoglobin. The
thermal damage5. deeper skin penetration also allows the physician to
Fractional photothermolysis is a relatively new target the dermal melanin. The low-dose QS Nd:YAG laser
concept in laser therapy in which multiple microscopic induces sub-lethal injury to melanosomes, causing
zones of thermal damage are created, leaving the fragmentation and rupturing of the melanin granules
majority of the skin intact. The fractional laser emission into cytoplasm. This effect is highly selective for
takes place by means of dots (DOT therapy) that generate melanosomes as the wavelength is well absorbed by the

54 September 2013 | prime-journal.com

 | Dermatology | peer-review

melanin in other structures (Figures 1–3). The QS Nd:YAG,

with its longer wavelength, is the safest type of laser for
treating darker skinned patients11–12.

Q-switched alexandrite
The longer 755 nm wavelength of the QS alexandrite
laser allows for deeper penetration into the skin. Unlike
others in Q-switched range, the alexandrite laser can be
used in short pulse (5 ms) emissions (Figure 5). This type
of laser enables selective damage of the pigmentation;
however, there is a higher risk of dyschromia, rather than
scarring or post-treatment hyperpigmentation. A number
of studies suggest that a possible combination of low-
energy QS alexandrite and QS Nd:YAG may also be
effective in treating hyperpigmentation, especially that
of the ‘light brown’ variety13–14.
Figure 4 A patient with a facial melasma with the pigment almost along forehead wrinkles

Intense pulsed light

IPL is a non-laser light source that emits light in the range
of 515 nm (red/yellow) to 1200 nm (infrared). The
advantage of IPL is the versatility of the parameters. The
wavelength, fluence, number, duration, and delay of
pulses can be adapted to each patient in order to
effectively target the chromophores. It can therefore be
used to treat a variety of conditions, including vascular
lesions, melanocytic lesions, and for hair reduction15.
In the authors’ experience, the use of IPL enables
ablation of very superficial pigmented lesions with
partially selective thermal damage and a low incidence
of scarring, but with a high risk of discolouration
(Figures 4–5). The laser settings play an important role in
the treatment. Initially, 500–550 nm filters can be used for
epidermal lesions, while higher wavelength filters can be Figure 5 After three intense pulsed light (IPL) (Photosilk Plus, DEKA Laser, Florence, Italy) sessions and
used to target deeper melanin; for example, in patients one session of the short-pulse alexandrite laser (Synchro Repla:Y, DEKA Laser, Florence, Italy)
with dermal/mixed melasma. The fluence can be hyperpigmentation is reduced
adapted to suit the treatment sites: a higher fluence can
be used for cheeks and zygoma, while the areas melanocytes, as well as an increase in melanin synthesis
surrounding the eyes and neck require lower fluences. via stimulation of tyrosinase activity and
Higher fluences are useful for deeper lesions, but can tyrosinase‑related protein-1 (TRP-1)21.
cause PIH in darker-skinned patients. Single pulses are One study has shown that melasma is characterised
effective in heating the pigment, but double or triple by alterations in the dermal structures in addition to
pulses should be used as they reduce thermal damage, pigmentary changes, suggesting a role of the dermis in
allowing the epidermis to cool while the target stays melasma development22. The role of fibroblasts in
warm16–18. melasma development has also been suggested. In fact,
the over-expression of both stem cell factors (SCFs) from
Melasma fibroblasts and c-kits has been found: the
Melasma is a commonly-acquired, localised fibroblast‑derived cytokines stimulate proliferation and
hyperpigmentation disorder characterised by irregular melanogenesis of melanocytes in culture. Therefore, it is
brown or gray–brown macules and patches with possible that the dermal inflammation induced by an
well‑defined margins that occur symmetrically on accumulation of UV irradiation may be associated with
sun‑exposed areas of the body, usually the face19–20. This the activation of fibroblasts, which results in the
condition typically affects women of child-bearing age, upregulation of SCFs in dermal melasma, leading to
and solar and UV exposure are the best known aetiologic increased melanogenesis22. Recent data has also shown
factors. Histological and immunohistochemical studies that melasma lesions have greater vascularisation than
have shown that melasma skin presents features of normal perilesional skin. An increased expression of the
prominent solar damaged skin. UV irradiation is known vascular endothelial growth factor (VEGF) in
to increase the synthesis of alpha-melanocyte‑stimulating keratinocytes has been suggested as a major angiogenic
hormone (α-MSH) and adrenocorticotropic hormone factor for altered vessels in melasma23; therefore, the
(ACTH) derived from proopiomelanocortin (POMC) in network of cellular interactions between keratinocytes,
keratinocytes. These peptides lead to the proliferation of fibroblasts and perhaps vasculatures and melanocytes

prime-journal.com | September 2013 55

peer-review | Dermatology |

during chronic sun exposure may play an important role which was significant compared with the control group.
in the development of melasma, working in conjunction However, 13.6% of patients developed faint, spotty
to stimulate melanocytes, resulting in epidermal hypopigmentation that improved during follow-up.
hyperpigmentation. Furthermore, 18% of patients developed rebound
Melasma can be classified depending on the site of the hyperpigmentation, and all patients had a recurrence of
lesions (craniofacial, malar, mandibular), histological melasma.
depth of the pigmentation (epidermal, dermal, mixed), Jeong et al27 compared the clinical efficacy and adverse
and appearance under the Wood’s lamp (epidermal, effects of the low fluence QS Nd:YAG (1064 nm) laser
dermal, mixed, indeterminate): when performed before and after treatment with topical
■■ Epidermal: light brown with an enhancement of triple‑combination (TC) creams using a split-face
pigmentation under the Wood’s lamp. Histologically cross‑over design in 13 patients with melasma. They used
characterised by a melanin increase in the basal, a collimated 5–7 ns pulse width, 7 mm spot size, and a
suprabasal and stratum corneum layers fluence of 1.6–2.0 J/cm2. Weekly sessions were carried out
■■ Dermal: ashen or blue–grey with no enhancement of for 8 weeks. The laser was compared with pre- or
pigmentation under the Wood’s lamp. Histologically post‑treatment TC cream. The authors found that
there is a predominance of melanophages in the pre‑treatment with TC creams was more effective as this
superficial and deep dermis decreases melanin production before laser injury;
■■ Mixed: dark brown with enhancement of therefore the risk of PIH is reduced and the melasma
pigmentation under the Wood’s lamp in some areas improves. If TC cream is used after laser treatment, the
only melanin is produced at full capacity with a higher risk of
■■ Indeterminate: not detected under the Wood’s lamp. PIH and less improvement in the melasma. Consequently,
The best therapeutic results are normally achieved in the authors recommend medical treatment for
epidermal melasma24–25. The laser to be used must be hyperpigmentation for at least 8 weeks before laser
selectively chosen and should generally be used in cases treatment in order to achieve optimal results.
in which there is proven resistance to conventional Kauvar28 assessed the safety and efficacy of a
treatments. procedure combining microdermabrasion, a topical
regimen, and low fluence QS Nd:YAG laser treatment in
Q-switched lasers 27 female subjects. In particular, low fluence QS Nd:YAG
In the past, attempts to treat melasma with lasers that laser treatment of 1.6–2 J/cm2 with 5 mm or 6 mm spot was
targeted melanin, such as the QS ruby laser (694 nm), administered immediately after microdermabrasion.
short-pulsed green dye laser (504–510 nm), QS Treatments were repeated at 4-week intervals.
neodymium laser (1064 nm), and argon laser (514 nm), Twenty‑two subjects (81%) had more than 75% clearance
yielded disappointing results. For example, in a of melasma; 11 subjects (40%) achieved more than 95%
randomised controlled trial conducted by Wattanakrai et clearance. Most subjects showed more than 50%
al26, 22 patients with dermal or mixed melasma were clearance of their melasma 1 month after the first
treated with the same laser at a fluence of 3–3.8 J/cm2 for treatment. Side-effects were limited to mild
five sessions at 1-week intervals. The treatment was post‑treatment erythema, which developed after the
combined with 2% hydroquinone and compared with microdermabrasion and lasted approximately 30–
hydroquinone alone. There was a 92.5% improvement, 60 minutes. Remission lasted for at least 6 months.
Figure 6 A multispectral
evaluation of the melanin
content of pigmented lesions

Figure 7 The same evaluation

of Figure 6, searching the
haemoglobin content

56 September 2013 | prime-journal.com

 | Dermatology | peer-review

CO2 and IPL spares the tissue surrounding each MTZ, thus allowing
Better results can be obtained with Er:YAG laser for rapid re-epithelialisation and fast epidermal repair Key points
resurfacing, and the combination of pulsed CO2 laser and owing to the small size of the lesions and short migratory
n Laser devices have
QS alexandrite laser as the CO2 laser destroys the paths for the keratinocytes. In studies by Kroon et al, revolutionised the
melanocytes, while the alexandrite laser removes the non‑ablative 1550 nm fractional laser therapy proved to treatment of many
pigment left in the dermis. IPL is a non-coherent, be a safe treatment option for patients with darker skin dermatological
broad‑spectrum light source that emits a continuous types when topical bleaching was ineffective or not conditions, including
spectrum in the range of 500 nm to 1200 nm. Its tolerated37. pigmentary disorders.
They have been widely
therapeutic efficacy is relatively higher in patients with Niwa Massaki et al38 investigated the efficacy and used with variable levels
epidermal melasma than those with mixed melasma29. safety of a single administration of a high-density of success for the
This phenomenon could possibly be related to the fractional thulium fiber laser (1927 nm) at 10 or 20 mJ/cm2 treatment of pigmented
location of the melanin. In epidermal melasma, the for the treatment of refractory melasma in 20 patients. conditions
melanosomes in the epidermis rapidly migrate to the Mean MASI scores decreased dramatically from 13.2 ± 5.4 n The ideal aim of laser
skin surface and shed off with microcrusts. In mixed before treatment to 8.5 ± 3.5 at 4 weeks after laser therapy is to reduce the
appearance of
melasma, the melanin-laden macrophages in the dermis treatment (P=0.004). Patient assessment revealed that 12 chromatic alterations, as
are barely damaged30–31. In a 2010 study, Zoccali et al32 had of the 20 subjects had more than 50% clearance of their well as reduce the risk of
excellent results with the use of IPL in melasma: they melasma. Recurrence was reported in seven out of 15 disfiguring scars and
treated 38 patients (with Fitzpatrick phototypes III–IV) patients who were successfully followed-up (mean permanent dyschromia
with IPL over three-to-five sessions at intervals of 40–45 10.2 months). n Melasma can be
classified depending on
days, using a 550 nm handpiece since it offers great The biological role of cutaneous blood vessels in the
the site of the lesions,
selectivity for melanin and reaches the deeper epidermis, pathogenesis of melasma is an interesting topic and histological depth of the
two pulses of 5–10 ms with a 10–20 ms delay between opens new therapeutic perspectives. Recently, the pigmentation, and
pulses, while the fluence was modulated with regard to authors performed a prospective study for evaluating the appearance under the
the anatomic area. Energy levels of 12–14 J/cm2 were used effects of pulsed dye laser (PDL) therapy. After a Wood’s lamp
to treat the cheeks and zygoma, 10–12 J/cm2 for the multispectral study for evaluating haemoglobin and n It is essential to carry
out a precise clinical,
forehead, while lower levels (7–8 J/cm2) were used on the melanin components, the authors are using this vascular
dermatoscopic and
area around the eyes and neck. Results were excellent in laser with a low fluence and have obtained some notable multispectral evaluation
18 patients (47.37%), good in 11 (28.95%), moderate in five improvements6–8. It would be tempting to think that the of the pigmentation to
(13.16%), and poor in four cases (10.52%), in which a action of PDL on vascularisation might have played an select the most
recurrence of hyperpigmented areas occurred within important role in preventing relapse. By targeting appropriate treatment
and ensure adequate
2–4 months32. Side-effects were minimal and included a vascularisation and at least some part of the elastosis in post-treatment care and
burning sensation during treatment and erythema for a the melasma lesions, it might be possible to decrease the follow-up
short period. Possible complications included transitory stimulation of melanocytes and thus reduce the
hyperpigmentation, persistent hypopigmentation, and incidence of relapse.
rarely, scarring.
A 10-week, split-face study by Goldman et al33 evaluated Conclusions
the safety and efficacy of TC cream when used All the laser devices discussed in this article represent
sequentially with IPL in patients with moderate-to-severe new horizons for the treatment of hyperpigmentation
melasma versus an inactive control cream associated disorders, and particularly in darker-skinned patients
with IPL at 2 and 6 weeks. The melasma area severity (Fitzpatrick skin types IV–VI). The use of lasers and
index (MASI) was significantly less with TC cream and pulsed light in the treatment of benign superficial
IPL than with inactive cream and IPL at weeks 6 (P=0.007) pigmented lesions has revolutionised the possibilities of
and 10 (P=0.002), and the treatment was well tolerated, therapeutic responses available for the dermatologist.
although cutaneous irritation was greater with IPL plus Physical treatment with lasers (especially IPL) is
TC cream than with IPL plus inactive cream (P<0.25 for all usually limited to those patients who fail to respond to
assessments). primary topical and cosmetic treatment. However, in the
In the authors’ opinion, IPL can be considered a valid authors’ experience — and particularly in the treatment of
therapeutic option — particularly in non-responders to melasma — it is only possible to obtain transient results
conventional topical agents — however, only temporary with the likely reappearance of hyperpigmented lesions.
and transient results can be achieved as there is repeat Physical methods using lasers sometimes yield rebound
onset of hyperpigmentation lesions after a few weeks or hyperpigmentation.
months. The importance of the role of vascularisation in the
Fractional resurfacing is a novel concept of skin pigmentation process must be studied further. This field
rejuvenation that has the potential to treat a variety of of research may provide new therapeutic options, such
epidermal and dermal conditions34. It produces a unique as vascular lasers or anti-angiogenic agents. It is essential
thermal damage pattern. In contrast to ablative skin to carry out a precise clinical, dermatoscopic and
resurfacing and non-ablative skin resurfacing, which multispectral evaluation of the hyperpigmentation in
achieve homogenous thermal damage at a particular order to select the most appropriate treatment and
depth, fractional resurfacing creates microscopic thermal ensure adequate post-treatment care (photoprotection)
lesions (i.e. MTZs)35–36. Fractional resurfacing specifically and follow-up, as well as the quality and maintenance of

prime-journal.com | September 2013 57

peer-review | Dermatology |

results.

Declaration of interest none 

Figures 1–7 © Dr Paolo Bonan et al

References
1. Arora P, Sarkar R, Garg VK, Arya L. Lasers for treatment of Q-switched alexandrite laser alone for refractory melasma: 27. Jeong SY, Shin JB, Yeo UC, Kim WS, Kim IH. Low-fluence
melasma and post-inflammatory hyperpigmentation. J Cutan split-face design. DermatolSurg 29:59-64, 2003 Q-switched neodymium-doped yttrium aluminum garnet laser
Aesthet Surg 2012; 5(2): 93–103 14. Nouri K, Bowes L, Chartier T, Romagosa R, Spencer J. for melasma with pre- or post-treatment triple combination
2. Konda S, Geria AN, Halder RM. New horizons in treating Combination treatment of melasma with pulsed CO2 laser cream. Dermatol Surg 2010; 36(6): 909–18
disorders of hyperpigmentation in skin of color. Semin Cutan followed by Q-switched alexandrite laser: a pilot study. Dermatol 28. Kauvar AN. Successful treatment of melasma using a
Med Surg 2012; 31(2): 133–9 Surg 1999; 25(6): 494–7 combination of microdermabrasion and Q-switched Nd:YAG
3. Anderson RR, Parrish JA. Selective photothermolysis: precise 15. Moreno Arias GA, Ferrando J. Intense pulsed light for lasers. Lasers Surg Med 2012; 44(2): 117–24
microsurgery by selective absorption of pulsed radiation. melanocytic lesions. Dermatol Surg 2001; 27(4): 397–400 29. Wang CC, Hui CY, Sue YM, Wong WR, Hong HS. Intense pulsed
Science 1983; 220(4596): 524–7 16. Kawada A, Asai M, Kameyama H et al. Videomicroscopic and light for the treatment of Refractory Melasma in Asian persons.
4. Emerson R, Ash C, Town G, Donne K, Omi T, Daniel G. histopathological investigation of intense pulsed light therapy Dermatol Surg 2004; 30(9): 1196–200
Pigmentation: selective photothermolysis or non-specific skin for solar lentigines. J Dermatol Sci 2002; 29(2): 91–6 30. Chan HH, Kono T. The use of lasers and intense pulsed light
necrosis using different intense pulsed light systems? J Cosmet 17. Figueiredo Souza L, Trancoso Souza S. Single-session intense sources for the treatment of pigmentary lesions. Skin Therapy
Laser Ther 2013; 15(3): 133–42 pulsed light combined with stable fixed-dose triple combination Lett 2004; 9(8): 5–7
5. Manaloto RM, Alster TS. Erbium:YAG laser resurfacing for topical therapy for the treatment of refractory melasma. 31. Li YH, Chen JZ, Wei HC et al. Efficacy and safety of intense
refractory melasma. Dermatol Surg 1999; 25(2): 121–3 DermatolTher 2012; 25(5): 477–80 pulsed light in treatment of melasma in Chinese patients.
18. Zaleski L, Fabi S, Goldman MP. Treatment of melasma and the Dermatol Surg 2008; 34(5): 693–700
6. Karsai S, Raulin C. Fractional photothermolysis: a new option
for treating melasma? Hautarzt 2008; 59(2): 92–100 use of intensepulsedlight: a review. J Drugs Dermatol 2012; 32. Zoccali G, Piccolo D, Allegra P, Giuliani M. Melasma treated
11(11): 1316–20 with intense pulsed light. Aesthetic Plast Surg 2010; 34(4):
7. Katz TM, Glaich AS, Goldberg LH, Firoz BF, Dai T, Friedman 486–93
PM. Treatment of melasma using fractional photothermolysis: a 19. Prignano F, Ortonne JP, Buggiani G, Lotti T. Therapeutical
report of eight cases with long-term follow-up. Dermatol Surg approaches in melasma. Dermatol Clin 2007; 25(3): 337–42 33. Goldman MP, Gold MH, Palm MD et al. Sequential treatment
2010; 36(8): 1273–80 with triple combination cream and intense pulsed light is more
20. Gupta AK, Gover MD, Nouri K, Taylor S. The treatment of efficacious than sequential treatment with inactive (control)
8. Katz TM, Goldberg LH, Firoz BF, Friedman PM. Fractional melasma: a review of clinical trials. J Am Acad Dermatol 2006; cream and intense pulsed light in patients with moderate to
photothermolysis in the treatment of postinflammatory 55(6): 1046–65 severe melasma. Dermatol Surg 2011; 37(2): 1–10
hyperpigmentation. Dermatol Surg 2009; 35(11): 1844–8 21. Victor FC, Gelberg J, Rao B. Melasma: a review. J Cutan Med 34. Beylot C. Ablative and fractional lasers. Ann Dermatol
9. Taylor CR, Anderson RR. Ineffective treatment of refractory Surg 2004; 8(2): 97–102 Venereol 2008; 135 Suppl 3: S189–94
melasma and postinflammatory hyperpigmentation by 22. Young Kang H, Ortonne J-P. Melasma Update. Actas 35. Tannous Z, Astner S. Utilizing fractional resurfacing in the
Q-switched ruby laser. J Dermatol Surg Oncol 1994; 20(9): 592–7 Dermosifiliogr 2009; 100(Suppl 2): 110–3 treatment of therapy-resistantmelasma. J Cosmet Laser Ther
10. Jang WS, Lee CK, Kim BJ, Kim MN. Efficacy of 694-nm 23. Young Kang H, Ortonne J-P. What should be considered in 2005; 7(1): 39–43
Q-switched ruby fractional laser treatment of melasma in treatment of Melasma. Ann Dermatol 2010; 22: 373–8 36. Karsai S, Raulin C. Fractional photothermolysis : a new option
female Korean patients. Dermatol Surg 2011; 37(8): 1133–40 24. Gilchrest BA, Fitzpatrick TB, Anderson RR, Parrish JA. for treating melasma? Hautarzt 2008; 59(2): 92–100
11. Lee MW. Combination 532-nm and 1064-nm lasers for Localization of melanin pigmentation with Wood’s lamp. Br J 37. Kroon MW, Wind BS, Beek JF et al. Non-ablative 1550-nm
noninvasive skin rejuvenation and toning. Arch Dermatol 2003; Dermatol 1977; 96(3): 245–8 fractional laser therapy versus triple topical therapy for the
139(10): 1265–76 25. Nakayama H, Harada R, Toda M. Pigmented cosmetic treatment of melasma: a randomized controlled pilot study. J
12. Choi M, Choi JW, Lee SY et al. Low-dose 1,064-nm Q-switched dermatitis. Int J Dermatol 1976; 15(9): 673–5 Am Acad Dermatol 2011; 64(3): 516–23
Nd:YAG laser for the treatment of melasma. J Dermatol Treat 26. Wattanakrai P, Mornchan R, Eimpunth S. Low-fluence 38. Niwa Massaki AB, Eimpunth S, Fabi SG et al. Treatment of
2010; 21(4): 224–8 Q-switched neodymium-doped yttrium aluminum garnet (1,064 melasma with the 1,927-nm fractional thulium fiber laser: a
13. Angsuwarangsee S, Polnikorn N. Combined ultrapulse CO2 nm) laser for the treatment of facial melasma in Asians. retrospective analysis of 20 cases with long-term follow-up.
laser and Q-switched alexandrite laser compared with Dermatol Surg 2010; 36(1): 76-87 Lasers Surg Med 2013; 45: 95–101

58 September 2013 | prime-journal.com