Patient A came to us at our clinic in Beaconsfield and presented with stubborn and severe melasma. She had previously tried topical treatments with inconsistent results before enquiring about laser options. Her melasma was making her feel self-conscious, and she was constantly using large amounts of foundation, which was having other negative effects on her skin health.
Melasma is commonly seen and is a hypermelanosis characterised by irregular light to dark brown macules and patches on sun-exposed areas of the skin. Often, other pigmentary disorders present in combination with melasma. These disorders can include post-inflammatory hyperpigmentation (PIH), pigmented contact dermatitis and acquired bilateral nevus of Ota. The incidence of melasma is often tied to hormonal changes and sun exposure and is more common for women and in skin of colour. The first line for the treatment of melasma includes topical agents and chemical peels in our clinic. We commonly have our patients use the Obagi NuDerm or Obagi-C RX System to treat various forms of hyperpigmentation. Though effective, there are concerns around side effects and long-term safety that necessitate alternative treatment options.
DR BENJI DHILLON
Dr Benji Dhillon is the founder and medical director of define clinic. He is a member of the Royal College of Surgeons, England and has undergone training in Plastic Surgery at some of the UK’s leading hospitals. As well as developing his own unique facial assessment algorithm, he is also a Global Key Opinion Leader and medical director for multinational aesthetic companies and has overseen multiple phase III and IV aesthetic clinical research trials. He has also published in several peerreviewed journals, including PRS and JCAD.
Laser and light therapy is a well-known treatment option that is promising in the management of melasma. Q-switched lasers have long been regarded as one such option, however, newer approaches using alternative laser types and wavelengths have been researched with various amounts of efficacy.
One such laser wavelength that is being used for melasma therapy is 1927nm thulium. Last spring, we evaluated the technology and decided to bring on the mJoule system by Sciton. The mJoule is a platform that combines a 1927nm fractional laser treatment (Moxi) with a powerful BroadBand Light device (BBL) that has the capability to deliver traditional BBL treatments or enhanced High Energy Rapid Output (HERO) protocols. The Moxi and BBL treatments are often combined in a single session for synergistic effects. The 1927nm wavelength has a high absorption coefficient for water, allowing us to precisely target the epidermis with minimal dermal effect. We do this by using the treatment interface to select laser treatment depths with a maximum penetration of 200 microns.
As explained, patient A came to us with the classic pigmented lesions that are associated with melasma. We provided an in-depth patient consultation to make sure we understood her top priorities and relevant medical history. In addition, we took time to educate her on what melasma is, what can cause it to flare up, and potential management strategies. All patients complete thorough photographic documentation using the Canfield Vectra imaging system. We love using this technology for consistent, high-quality images and allowing the patient to see their progress.
Based on her treatment history, skin pathology and the indication, we decided that a course of 1927nm Moxi fractional laser treatments would be most appropriate. We recommended a package of three Moxi sessions spaced four to six weeks apart for melasma. Though we commonly use BBL for skin rejuvenation, we consider it a contraindication for melasma due to the potential for the heat and light to cause the condition to worsen. This cautious approach is common for less powerful IPL devices as well.
On the day of her treatment, the patient completed our standard cosmetic laser treatment consent in which we particularly focus on these critical points specific to melasma therapy:
• We cannot guarantee permanent improvement of their melasma. We feel it is very important for patients to understand this is management versus correction due to the challenging nature of melasma
• Strict compliance to sun exposure and SPF protocol is mandatory
• Any event that might cause hormonal change can cause melasma to return.
After a thorough cleansing of the face, we applied EMLA topical numbing cream for 20-30 minutes prior to treatment. For additional comfort, we used a cryo chiller to allow the patient to blow cold air on their face during and after treatment. The Moxi 1927nm laser uses a rolling application to deliver the laser energy. The roller doubles as a measuring tool, which was the first step in this case. By taking a quick measurement of the lower face, forehead and nose, we ensured that we are delivering a precise amount of energy to hit our treatment parameters. Here, we used 5j of energy at a 10% coverage. The machine told us when we had hit our energy targets for each treatment zone to reach full-face coverage, which we completed in about nine mins.
Immediately after the treatment, the patient experienced a hot, sunburn-like sensation that is typical and tends to last one to three hours. She was provided with Teoxane Deep Repair Balm to use as needed during the healing process to keep her face well hydrated. We also had her gently wash her face in the morning and evening using a gentle cleanser. All patients are provided explicit post-care instructions which outlines everything mentioned. Again, when treating melasma, we particularly emphasise avoiding anything that would cause excessive heat buildup in the first week and minimising sun exposure.
HEALING AND RESULTS
Our patients experience a very easy healing process after the Moxi treatment for three to five days. The main thing they see is the formation of MENDs. This is an acronym that stands for Microscopic Epidermal Necrotic Debris. Essentially, she had very small packets of dead skin from where the laser energy absorbed into her skin. We describe the feeling of the skin as being similar to finegrit sandpaper. It becomes progressively dryer and rougher prior to a light peel on day four or day five. Keeping the skin well hydrated with our post-care product is important for speeding up this process.
Our patient was absolutely thrilled with these results for her severe melasma. Firstly, she saw significant lightening of the pigmented areas. In addition, her overall skin tone became brighter and healthier looking. Finally, she described improvements we commonly hear about with laser resurfacing that don’t always translate to a picture, such as smoother texture and much easier application of products and makeup. Melasma is a very challenging condition and can cause significant emotional distress for patients. By offering an efficacious procedure with minimal downtime, we are able to offer patients like this not only aesthetic improvement but also increased confidence and happiness.
Medical Lasers; Engineering, Basic Research, and Clinical Application (2017) Rho, Nark-Kyoung, Treatment of Melasma Using a Novel 1,927nm Fractional Thulium Laser