Upload
others
View
3
Download
0
Embed Size (px)
Citation preview
Menegament of Melasma
with
Ablative Laser Treatment ŞERAFETTİN SARAÇOĞLU, MD
DERMATOLOGIST
MELASMA
Acquired
Symetric
Hypermelanosis
Age 30-55 years
♀/♂: 90/10
Epidermal
Dermal
Mixt
Mechanism of action of main bleaching
agents used to treat melasma (adapted
Gupta et al., 2006)
Mecanism of action Substance
Tyrosinase inhibition Hydroquinone
Tretinoine
Azelaic acid
Kojic Acid
Non-selective suppretion of
Melanogenesis
CS
İnhibition of ROS Azelaic acid
Melanin removal Chemical peeling
Thermal damage Lasers
Melasma Laser Treatment
Non –ablative
Q-SW Ruby
Q-SW Alexandrite
Q-SW Nd-YAG
Cu-Bromide
FLPDL
IPL
Ablative
CO2
Er-YAG
Thulliım
Ablative Laser Treatment of
Melasma
Laser resurfacing
Fractional resurfacing
Laser resurfacing; Er-YAG
• Rhesa May at al.,
• Postpeel results
• Imidiate results excellent
• 3rd-6th week PIH (universal, all patients)
• GA peeling beweekly
• Bleaching regimen
• 6th month MASI score significantly decreased
• Conclusion: Perform just for refractory melasma patients
• Rhesa May, P. Manaloto and Tina Alster. “Erbium:YAG Laser Resurfacing for Refractory Melasma.” Dermatologic Surgery 1999 : 121
Melasma;
Ablative Laser Treatment with Er-YAG
Manaloto et al., 1999
CS, N=10
ER-YAG ( Continuum Biomedical, Dublin, CA) 1-1.5 J (5.1-7.6J/cm2), 5
mm spot, 8 Hz
PIH 3-6 weeks after procedure
Azelaic acid 20% cream, GA peeling beweekly
Manaloto RMP, Alster TS. Erbium:YAG laser resurfacing for refractory melasma. Dermatol Surg.1999;25:121–3
Fractional laser (nonablative)
RokhsarCK, Fitzpatrick RE. The treatment of melasma with fractional photothermolisis: A Pilot study. Dermatologic Surgery. 2005;31:1645-50
Geronemus, R. G. (2006), Fractional photothermolysis: Current and future applications. Lasers Surg. Med., 38: 169–176. doi: 10.1002/lsm.20310
Goldberg DJ, Berlin AL, Phelps R. Histologic and ultrastructural analysis of melasma after fractional resurfacing. Lasers Surg Med. 2008;40:134–8
Non-abalative Fractional treatment has signficant improvement effect on the melasma pecthes Melanocyte count is decresed
But at 6th month follow-up, recurrence was noted in 50% patients
Melasma;
Fractional Ablative Laser Treatment with
Er-YAG
Wanitphakdeedecha et al, 2009
CS, N=20 ♀, Epidermal Melasma, 2 treatments 1 month apart
VSP Er-YAG ( FidelisM320A, Fotona, Ljubliana, Slovenia) 160 mJ(0.4
J/cm2), 300 µs PW, 7 mm spot, 10 Hz
PIH (n=3)cleared spontaneously within 2 weeks
Acneiform eruption (n=2) treated with clindamycin and adapalene
15% of patient had 50 % improvement
Melasma;
Fractional Ablative Laser Treatment with
CO2 Trelles et al., 2010 RCCT
30 woman FSP II-V
GroupA. Kligman’s formula + TT2 ☼ cream (n=10)
GroupB. CO2 laser ( n=10)
GroupC. CO2 laser + TT2 cream ( n=10)
Laser: Ultrapulse Active FX Lumenis, Yorknaem, Israel) 7.5 W, 150 mJ( (11.3 J/cm2), 350 ms PW, 50 Hz
1st mounth A,B,C groups absence of complications
QoL index 100% all groups
MASI score decreased A,B group 12 mounth of follow-up, stabil at C group
TrellesMA, Velez M, Gold MH. The treatment of melasma with topical creams alone, CO2 fractional ablative
resurfaceing, or a combination of the two: a comperative study. J. Drugs Dermatol. 2010; 9:315-22
☼ TT2: Hydroquinon2%,Kojic acid 2%, GA
Melasma;
Fractional Ablative Laser Treatment with
Thullium Laser Polder et al.
CS, N=14
Thullium Fiber Laser ( Fraxel Dual, Solta Medical, USA)10-20 mJ, 252-
784 MTZ/cm2,
3-4 treatment, 4 week intervals
51% improvement, PIH (-)
34% MASI score at 3rd-6th month post treatment follow-up
Polder KD, Bruce S. Treatment of melasma using a novel 1,927 nm fractional thulium fiber laser: A pilot study. Dermatol Surg. 2012;38:199–206
Melasma;
Combined Ablative + Non-ablativeLaser
Treatment Idea;
Ablative: Remove epidermal melanin & melanocyt
Non-Ablative: Remove melanin in dermal melanophages
Angsuwarangsee et al.
N=6,
Right: QSAL
Left: Ultrapulse CO2 + QSAL
Significant response combination treatment site
Contact dermatitis & PIH
Hence: Just for refractory melasma Angsuwarangsee S, Polnikorn N. Combined ultrapulse CO2 laser and Q-switched alexandrite laser compared with Q-switched alexandrite laser alone
for refractory melasma: Split face design. Dermatol Surg.2003;29:59–64
Coclusion
In the management of melasma with ablative lasers is controversial
Thullium laser seems to promissing laser type for epidermal melasma
Needs further investigation
Topical bleaching agents remain the gold standart treatment
Combining pre&post laser and topical treatment greater efficacy
compared to treatments alone
Melasma; My Treatment Approach
Topical Treatment
Kligman formulation or TTT
Dermamelan peeling system
Sunscreen SPF 30+ or opaque
Oral Medication
Tranexamic acid 1500 mg/day PO
NAC 400 mg/day PO
Mesotherapy
Tranexamic acid + NAC +Vit-C equal, 0.01 ml/ cm2 weekly intervals
Laser
FPDL 585 nm, 7 mm spot, 2-2.5 J/cm2
Q-SW Nd-YAG 1064 nm, 6 mm spot, 0.6-1 J/cm2
Dermamelan Peeling
Before 3 Month after
Melasma + PIH
Before 8 Month After
Melasma + PIH
Before 5 Month after
Melasma PIH
Before 5 Month after
Thank you Serafettin Saracoglu, MD