Dr. Chua Cheng Yu: It’s 2022. Have Melasma Treatments Finally Improved?

Dr. Chua Cheng Yu: It’s 2022. Have Melasma Treatments Finally Improved?

Melasma is notorious for being one of the most difficult pigmentations to treat. Why? Hi, my name is Dr Chua Cheng Yu. At my practice in Veritas Medical Aesthetics, a good portion of patients who consult for melasma express disheartenment when previous treatments at other places fail to yield improvements.

• May occur with other forms of pigmentation
• High chance of recurrence or relapse
• Affects multiple layers of the skin
• If treated incorrectly, it can worsen in severity

It is not uncommon for patients with melasma to bounce from doctor to doctor due to dissatisfaction with the results of their treatments, as melasma is a condition where there isn’t a one size fit all treatment protocol.

Current available treatments for Melasma include:

• Topical Creams –  4% Hydroquinone, tretinoin, azelaic acid, cysteamine, kojic acid
• Oral medication – Tranexamic acid
• Lasers – Low fluence Q switched Nd YAG or picosecond Q switch Nd YAG, Pulsed dye laser
• Chemical peels –  Glycolic acid and trichloroacetic acid (TCA) are among the peels commonly prescribed

The question is: are these treatments still effective?

The answer is: Yes, they are.

Will they always give you the best results?

No, definitely not.

Hence, the question remains: How can we separate the good treatments from the not?

I believe there are multiple important factors to take into account before we can conclude whether a treatment should be recommended or not. By identifying them, we will be able to determine the treatments best suited for the patient.

What are these factors?

Type of melasma – Is your melasma dermal? Epidermal? Mixed? It is important to identify the skin layer involved as it impacts my treatment decision. For example, epidermal melasma usually responds well to topical lightening creams, while dermal and mixed types might require other additional types of treatment.

Medical history & past treatments – Patients may experience a rebound in their condition, especially so for those with melasma. Rebound melasma can happen when melasma is treated too aggressively, partially treated, or when lifestyle factors are not properly managed. For example, if chemical peels are used to treat melasma without caution, there is a possibility of a rebound and also side effects of skin irritation and post-inflammatory hyperpigmentation (PIH), which can be especially severe in darker skinned patients.

Timing, onset and duration of symptoms also need to be properly documented in order to establish a baseline prior to commencing treatment and to monitor improvement.

Patient’s health & lifestyle – I cannot stress how important this is. Even with a well-tailored treatment plan, it can be difficult to improve melasma if there is continued sun exposure, usage of wrong skincare products, or hormonal imbalances. 

Other underlying conditions – Melasma can co-exisit with other forms of pigmentation. Are there lentigenes as well? Does the patient also suffer from PIH? In many cases, I treat pigmentations in a specific order so as to avoid complications or further damage being done.

With a thorough understanding of these factors, I will be better able to design a treatment plan customised to the patient’s skin condition and lifestyle.

In my opinion, treating melasma in 2022 is no longer about using 1 or 2 separate methods. Over the years, Veritas Medical Aesthetics has built up a reputation for preferring combination treatments and we have more than 10 machines in our arsenal, each equipped with multiple unique lasers.

Many of our patients find this strange and often ask – why the need to recommend so many different lasers?

Isn’t there a single do-it-all laser to solve my pigmentation problems?

The reason we invest so much into different lasers is because – different lasers attack different factors.

Because of the various factors I’ve named – no single tool, no matter how well-marketed, can effectively resolve every component contributing to the development of melasma.

Let me give you the best example of this: Picolasers

Picosecond lasers have been touted by some as the answer to almost all forms of pigmentation. Many of my patients and colleagues alike have the opinion that picolasers are the best choice to treat melasma.

I have to be honest – while I believe picosecond lasers are good, it is only a single tool out of the many that we use to treat pigmentation at Veritas Medical Aesthetics. There is nothing radically different about picosecond lasers that allows them to fully treat conditions like melasma. The photomechanical effect a picosecond laser generates serves a similar function to what a nanosecond Q switch laser does. It is important to consider all the strengths and weaknesses of a tool before deciding it is the right one to treat a condition.

From my own personal experience, I would say that patients who only undergo picolaser treatments will generally see a 10-40% improvement after 3 treatments. While these results are respectable, they are definitely not the best.

Picolasers are like a larger, sharper sword to enter a fight – when others are attacking with guns.

Let’s talk about a patient of mine who went through melasma treatment fairly recently.

Being close to her 40s, being of a darker skin tone and having given birth recently, she pretty much fit the quintessential profile of a melasma patient. After closer examination, I realized that her melasma was of a vascular variant. This would mean treating both the dermal components of melasma as well as the vascular components.

After the first consultation, my initial prescription to her included:

• Topical 4% Hydroquinone cream
• Physical sunscreen (SPF 50 and PA+++) to be applied daily on sun exposed skin before leaving the house, with reapplication every 2-4 hours.

She returned to the clinic after 3 weeks for her first laser session.

I used a combination laser treatment of Quadrostar Pro Yellow Laser, Fotona Starwalker PICO, and Fotona Versa 3 for this patient. Why these 3 lasers, you might ask?

Let’s talk about each of them in more detail.

Quadrostar Pro Yellow Laser: Targets superficial blood vessels and pigmentation.

Fotona Starwalker PICO: Targets epidermal keratinocytes and deeper melanosomes

Fotona Versa 3: Targets deeper blood vessels that the Pro Yellow Laser cannot reach.

From this, we see that each laser was chosen to tackle a specific aspect in which melasma acts on skin. With a thorough understanding of the properties and mechanisms of each laser, I am able to choose the best suited treatment combo for each patient’s condition. Should her pigmentation present differently, the lasers I picked might have been completely different!

A combination approach also allowed me to reduce the total number of sessions needed to tackle her condition. After 3 laser sessions with a treatment period spanning 2.5 months, she saw significant improvement in her condition and we switched her to a topical regime for post-treatment maintenance.

So what can we learn from this patient’s case study? Simply put:

Single lasers don’t allow you to target specific components of complicated conditions.

Combination lasers, however, do.

Many doctors can and also are providing combination lasers, which is a step in the right direction. At the end of the day, I believe it is about having a thorough understanding of the condition as well as the components of skin involved in disease pathways, before deciding on a suitable laser setup to use in order to deliver safe and reliable results.

For example, the trio of Pro Yellow Laser + Pico + Versa 3 that I listed above is a combination that can be recommended to a proportion of melasma patients I see. This combination is but 1 of the many combinations we use at Veritas, and is a no downtime treatment. There are other combinations that range from no downtime to bloody faced options immediately after treatment! 

For those visiting Veritas clinic or are looking for laser solutions to melasma around Singapore, don’t be surprised if you notice a shift in doctors’ recommendation towards that of combination lasers. I believe that as our knowledge increases in the years to come, more effective combination treatments will become commonplace for treating complicated pigmentation conditions such as melasma.

Do you have a question for me?

I am more than happy to answer them at ask@veritas.com.sg and +65 6283 3885

References

(1) Trivedi, M.K. & Yang, F.C. & Cho, B.K.. (2017). A review of laser and light therapy in melasma. International Journal of Women’s Dermatology. 3. 10.1016/j.ijwd.2017.01.004. https://pubmed.ncbi.nlm.nih.gov/28492049/

(2) Sarkar R, Aurangabadkar S, Salim T, et al. Lasers in Melasma: A Review with Consensus Recommendations by Indian Pigmentary Expert Group. Indian J Dermatol. 2017;62(6):585-590. doi:10.4103/ijd.IJD_488_17 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5724305/

(3) Park YW, Yeo UC. Current and New Strategies for Managing Non-Responders to Laser Toning in the Treatment of Melasma.  Medical Lasers 2016;5:7-16.