Exchanging Clinical Information and Treatment Protocols about Melasma. Melasma is very difficult to treat. Many methods have been used - Hydroquinone, Cosmelan, Fraxel, Q-Switched Lasers and IPL. What is the most effective methods? Which will make Melasma worse? What is the best way to treat Melasma?

Is anyone having success with "the new" Cosmelan?
How is the Fraxel working for Melasma? Does it work? Does it last? Does it make Melasma worse?

What do you recommend for your patients when they come in complaining of Melasma? What is your Melasma Treatment Plan?

Comments Anyone?

IPL shows impressive improvement in tackling melasma among Asian patients

Melasma is common in the Asian population, and various therapies have been only mildly effective, but intense pulsed light therapy may be just the trick for helping to clear the condition, according to a new study.

A team of researchers treated 89 Asian women with melasma with a total of four IPL treatments at three-week intervals. Changes in the skin were evaluated with a skin colorimeter, the melasma area and severity index and by patients and blind investigators.

The results were impressive -- a 50% to 100% improvement was noted in as many as 69 (77.5%) of the patients and mean MASI scored dropped from 15.2 to 4.5. The researchers noted that patients with epidermal-type melasma showed a better response than the mixed-type of the condition. Adverse reactions were meanwhile reported to be minimal.

“IPL is a good option for patients with melasma,” the physicians concluded. “Adverse actions of IPL were minimal and acceptable”

The researchers said they had no significant interest with commercial supporters.

Read the study:
Dermatol Surg. 2008 May;34(5):693-700; discussion 700-1
(Registration required for full-text)

I am starting to get away from Fraxel for Melasma and I spoke with another very experience user last night who loves the Fraxel for Melasma. Are you using Fraxel for Melasma? How is it working? What settings are you using for skin types 1-3, skin type 4, skin type 5 and skin type 6? Do you limit your number of treatments to 3? What do you do after 3 treatments? Can you do more Fraxel treatments 6 months later? Do you just treat the "spots" or do you treat the whole face? What other measures are you recommending for your patients ie. sun avoidance, hydroquinone, Retin A?

We pre treat the entire face with Hydroquinone 4 % and Kojic acid for at least 14 days. The application of this mixture is stopped 4 days before a treatment with
15 % Salicylic Acid 1 layer to the entire face
followed by 10 % TCA overlays 3 to 4 layers to the affected areas in skin type 4 to 6 or 15 % to skin types 1 to 3

This procedure can be repeated 3 weeks later after once again having pe treated the area.

We also have our patients start on Ovelle, Pycnogenol a French Maritime pine bark extract to raise the level of resistance to the sun.Over a period of 3 months this seems to break up the pigmentation.

High dose MSM (4000 mg per day )also seems to help break up the melasma.

Hope this helps.

Also twice daily mandatory application of 5 mls of sun block pereferably Titanium Dioxide or micronisd Zinc Oxide.

Can anyone tell me if there has been any advances or up and coming clinical trials for the treatment of melasma/PIH?

I am a melasma sufferer, and I tell you I have tried it all with zero results. I am french/native American with Type 3 skin, mixed dermal and epidermal pigmentation. Obaji after 4 weeks caused hypopigmentation, I have done the TCA, done the glycolic, used and array of over the counter, taken the MSM, pycongel, high vitamin c, glucosomine and all kinds of other products. they do not work and I have spent thousands. I was never a sun worshipper, never taken birth control, have had my homrones tested, been to an alterative med doc and taken everything from chinese herbs to had needles under my skin. Had the fraxel which I ersonnaly feel is not worth it and a scam because it made it much worse.

It just seems the same treatment modalities are used over and over instead of trying something new. Have any of you taken a look at the fourm under SKINCARERX?

Margaret, what city and state do you live in?

I live in Virgina Beach, VA but I would go aywhere

Margaret, Contact me "off-line" at Jeff4459@aol.com. We are right outside of Philadelphia. We have an excellent and robust Melasma program. I am pretty sure we can help you (with Melasma there are no guarantees). In the subject line of your email write, "Margaret-MedicalSpaMD-Melasma". This way I will recognise, read your email and respond. JEE

How do you treat Melasma with the BBLs?

I do test spot with 515, 560, and 590 nm; 9 J/cm2, 15 ms, 15 C with the small round mask. See the patient back two weeks later and decide which worked best or not at all. I'll often pre- and post-treat with Tri-Luma 8 weeks before and after to help keep it gone but it often comes back.

Do you do Melasma test spots at 9-15 mj or just at 9 mj?
I do them at 9 J/cm2 with the small round mask usually. If there was no response but no adverse effects, I may do another one at 11-15 J/cm2.

What do you look for when you do test spots? Lightening? No darkening?
You look for immediate darkening (I say immediate but I mean 5 minutes after the pulse) without excessive redness or (God forbid) a grey-white color which indicates they are going to blister. I have them back in 2 weeks to evaluate lightening.

If there is no reaction at 9 mj, do you do another spot at 10 mj and continue to do another test spot each 5 minutes increasing the energy by 1 mj each time until you get darkening?

Sometimes, but I don't go much beyond 11 J/cm2 for the test spot. If there is absolutely no reaction, I'll instead use the 560 or 590 nm filters to try and get a response. You can be surprised by the ferocity of the reaction the next day, even to the lowest settings. That is why I don't get too aggressive with the test spot.

If you get darkening at 9 mj, do you do the treatment with the smallest mask at 9 mj or do you go to the big spot size and use a different energy or do you use 9 mj?

If at two weeks the pigmentation is resolved with the test spot, I'll use the same settings with the larger spot. This almost never happens. Usually, they get some minimal lightening with the test spot and then I'll be more aggressive with the actual treatment.I make sure the patient realizes it is a test spot and set their expectations low; the purpose of the test spot is primarily to test safety and tolerability. Assessing efficacy is secondary to safety

If your treatment does not improve the melasma, what do you do in terms of refunds, other treatments, etc?

My philosophy is that the patient is informed of the risk and our services are valuable, even if they don't work. I will occasionally comp follow-up treatments with the 590 nm BBL or give them free Tri-Luma but we do not give refunds. We are not Wal-Mart.

Do you try to distinguish between epidermal melasma and dermal melasma before you start treatments? Do you treat patients differently based on the type of melamsa they have?

You can do a Wood's light examination to distinguish between epidermal and dermal melasma but we rarely do this. Most melasma is mixed epidemal and dermal. We also have them pre-treat with Tri-Luma or Differin and that usually gets rid of the epidermal melasma. However, you might need very long pulse widths, lower cooling temperatures, and maybe even a Q-switched Alexandrite laser to really go after dermal melasma effectively.

Do you use Tri-Luma or EpiQuin Micro? Do you use Cosmelan?

Yes to Tri-Luma both before and after BBL. We usually have them pre-treat for 8 weeks and post-treat for 8 weeks. I don't use EpiQuin, Cosmelan, or Lustra anymore because Tri-Luma is so much more effective.

12.14.2008 | Dr. B's Student

My current treatment protocol for treatment of Melasma on my type IV patients are:
1) Daily liberal use of sun screen SPF 30 or greater BID. Apply thick layer over the affected area.
2) Triluma (Hydroquinone) cream over the affected area q HS for at least 2 weeks prior to any laser treatment. Resume Triluma cream only when skin has completely recovered from laser treatments.
3) Use of 1064 Q switched laser at the following setting. 3mm 5J at 10 Hz over the affected spots until I reach moderate erythema. I do not over treat to see petechea at these spots.

Regular follow up at 1 month interval is required. If hypo-pigmented spots begin to occur then the 1064 Q switch laser needs to be stopped. Melanocytes may be in a state of shock and require some time to grow back.

I tend not to use IPL treatments on Melasma because the hyperpigmentation is just to deep for the shallow treatment layer dealt by IPL devices.

I have had melasma for about 14 years. I have had chemical peels, used numerous creams and had different laser treatments and nothing has worked. It is extremely frustrating but i don't have money to try any more of these treatments. I have spent hundreds of dollars and at 39, i have the same problem. Any ideas?

Melasma is a long term problem. It is more management than treatment. You can have absolutely beautiful response to the different therapies but if you do not avoid sun exposure and tanning beds then you will end up back at square one.

As a physician, I like to use a combination of Obagi NuDerm with tretinoin and the Fraxel. I think the original Fraxel currently known as the ReStore is a better option than the CO2 lasers at this time. You will need 3 to 4 treatments and I would tell you to use the Obagi system for at least 6 months.

I hope this helps. I have seen 100% clearance in some of my patients but they also understand that they need to take care of their skin or it will very likely return.

I am hearing good things about the Dual Yellow Copper Bromide laser for melasma/hyperpigmentation but I am not seeing it used in the US. Does anyone know if it is?

RT@Margaret
Dual yellow laser is coming from www.norseld.com, I'm not sure about their distributor in the states. It use 578 nm [yellow] and 511 nm [green] wavelength for melasma treatment. Actually, it work for epidermal type than the dermal type. You may need to combine it with other methods for better results like IPL, mesotherapy, chemical peeel, laser toning. IMHO the best protocol is yet to come, have to learn more about this type of laser since Norseld still change their melasma protocol each month.

As a licensed medical aesthetician and an instructor in advanced aesthetics, I have had many clients with resistant melasma. My belief and experience is you cannot treat a chemical imbalance, which melasma is, with lasers. You need to fight a chemical with a chemical.

You can pre-treat until the cows come home, but all in all you are still putting that patient at risk for postinflammatory hyperpigmentation. Think about all things that will cause the melanocytes to go into overdrive- sun, uv beds and heat.
Lasers produce heat..

I just do not want to put my patients at risk for this to happen. Most of the time their self-esteem is low enough. Trust me on this, fight it with a chemical..If you want to know how, please feel free to email me. Promise. No charge..

LE,

Do not comment on anything you do not know.

@ Karen Sedler LE: "licensed medical aesthetician"?
As far as I'm aware, there's no 'medical license' for estheticians. If I'm uninformed please let me know where I can get my estheticians a medical license of some kind. (I'm overworked with all this medical stuff I have to do.)

PS: You also use the term "my patients", what does that mean?

Ouch!!! CanMD and SurfaceMD! Little harsh aren't you? This is a sharing forum and everyone should be allowed to express their views without fierce attacks on their character. If that's your attitude on someone trying to share, I sure do pity any estheticians who work for you!

OH My,

What did I say is harsh? What LE said is greatly mistaken. Please look at other people discussions. I have not said anything that is demenaing and condescending. I would say it even if you are a Havard MD and posting the same comment. What are you trying to say.

its not harsh , but its the truth . If you really concern about your "patient" ... then you have to accept it and learn more as in medicine the process of learning will never stop.

@LE
Any chemical treatments are my only choice 15 years ago but, laser and combination treatments are my way right now. IMHO, 1. No golden standard treatment for melasma
2. Each pateint need an individual protocols. I've done 5-8 Dual yellow treatment for melasma a day but, have to said that it's not work for everyone. You need to fine tune your treatment for each patient until you'll see the result.
3. This site is great for sharing information but, you have to verified everythings here before bring it to your practice.
regards;

i tried to contact Norseld the manufacturer of the Dual yellow laser to get the names of doctors, clinics or hospitals providing treatment for Melasma using the Dual yellow laser technology, but I have had no reply from them so far. I also send emails to some clinics in Bangkok whom I was informed could have this piece of equipment which is supposedy provides new successeefull treatement for melasma particularly on asian skin. So far I also have absolutely NO REPLY at all!!! Anybody can provide testimonials about treatment with Dual yellow laser??

I had amazing results with Cosmelan treatment from a fantastic dermatologist in LA. The results were remarkable and completely took away my melasma as well as marks from old pimples. You have to use the Cosmelan 2 cream everyday after on the location of former melasma spots because the C2 cream inhibits pigment production. You also must stay out of the sun--even with sunscreen. I didn't use the C2 everyday so the spots came back. I am going to do another treatment this summer. However, my spots are small and only on the sides of my nose as well as on my nose. Could be why I got really good results. It is still annoying regardless of how small the spots are!

Cutanis: How much are you asking for the VEINWAVE unit? What is the retail list for a nerw device? Do you know what the company charges to inspect and "certify" a used device? Do you know the monthly cost for an extended service agreement?

I am just an esthetician, but I have suffered with melasma for a very long time., and worked with doctors for 10 years, I have not tried Cosmelan, but I have used the Melanage Peel by Young Pharmaceuticals. It is very effective in controlling melasma. Nothing will get rid of it completely, and I have found that IPL will make it darker in some cases. I like predictability so I no longer treat my melasma patients with IPL. Laser Genesis is also great for controlling Melasma with no downtime. The parameters used are 16jcm 9hz. This is much better that IPL and will not make the melasma darker.

There is also what looks to be a reasonably effective product called LUMIXYL that is by prescription only. I haven't tried it in my patient base yet but plan to soon. Impressive pictures on their website.

Dear All,
OBAGI Nu Derm system has shown promising results. In India, we are using it on many clients and hey are too happy with it. Have all documented pre-post pics as well.
Luv,
Dr Goel
+91-9820646210

I had 2 fraxel treatments at a cost of $1,000. The treatments made my melasma a lot worse; the pigmented area spread and got darker. What disturbed me most is that my dermatologist, who is supposedly very reputable, did not even caution me that the treatments may make the melasma worse. Had I know this I would have never tried the Fraxel laser.

I am astounded at the number of doctors who recommend these very expensive so-called treatments, given the number of stories I have come across where people are devastated by the results. What happened to "heal, not harm."

Melasma is difficult to treat and it's very tempting to try anything to get rid of this condition, but please think twice before getting laser treatments.

I would like to know how you prepare the skin when treating darker skin types or Melasma patients with IPL?

Lumixyl seems promising. I would really appreciate the input of those who have tried this.

http://www.bizjournals.com/prnewswire/press_releases/2012/05/17/LA09148

I have excellent results removing melasma using micro fractional difractive lasers at 1064 nm.

Toby M.,

What the heck is a "micro fractional difractive laser at 1064nm"?

I have done all kinds of lasers but no result. Cosmelan also. I have melasma on the two sides of my face. Now trying dual yellow Laser for the second time. My advise is not to use triluma cream on your face. It only temporary lighten the area and cause harm to your skin. And also don waste your money on lasers, it doesnt help. I have yet to find one that can really lighten melasma.

Has anyone had issues with Norseld's Y Lite or Dual Yellow Lasers? Specifically the copper bromide tube longevity?

the indication from the Lutronic Spectra offers Melasma treatment.
Copperbromide vapor lasers has been around for quite some time. Expensive tubes when they need replacing. 3 to 5 year lifetime, need to ensure proper runtime on tubes

I spent thousands on laser treatments for melasma (dark spots on skin due to sun and hormones). The laser helped but the Made from Earth Skin Correcting Mist eliminates. I use it twice a day - morning and night.

I also used to use Retin A, but again the Made from Earth Correcting Mist worked so much better. Dark spots gone in 2-3 weeks.

Hello everybody , mu name is Monica and I am a cosmiatra. I just came here and I was reading from other doctor the experiences they have with Copper Bromine laser.. We are using it for most than a year. I am not so happy with the results . of 100% only 20% good. besides the tube is extremely expensive. and is very difficult to calibrate it . If somebody want to share with me theirs experience with this laser i will thank very much . myoka57@hotmail.com

im a 5 years melasma suffer,developed after fucked up chemical peeling in a stupid place wich eat my money and fucked my face.during pregnancy patches got woorth alot ,after delivery i used EXPIGMENT(hidroquinone) wich after 5-7 days begined fade away but also after stoped using it with sunblock +50 UVA UVB. it appeared back and larger patches.plus my skin was looking like im sick and lost elasticity alot.so i think HIDROQUINONE is not at all what the drs says.at the moment im using Azelaic Acid %20 evening plus %50 during day,there is a diference but it workss so much slow,in 4 moonth it lighten but size it enlarged :( i can hide it with some tinted sunscrean atleast now.im waiting maybe soon finally treatment for melasma will be discovered

Any experiences with treating melasma with medical dermal needling (1.5-3mm depth)? Success?