Journal of Clinical and Aesthetic Dermatology

APR 2018

An evidence-based, peer-reviewed journal for practicing clinicians in the field of dermatology

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28 JCAD JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY April 2018 • Volume 11 • Number 4 O R I G I N A L R E S E A R C H M Melasma is asymmetrical, blotchy, brownish facial pigmentation. It appears on parts of the face exposed to the sun such as the cheeks, forehead, and chin. It is reported more frequently among people with darker skin tones. 1 Although its pathogenesis is not completely understood, some factors involved include various vascular growth factors, genetic factors, H19, inducible nitric oxide synthase (iNOS), and Wnt pathway modulator genes. 2 Up to one-third of patients have a genetic predisposition to melasma. Melasma can be triggered by the sun, hormonal alterations (e.g., birth control pill), pregnancy, medication use (e.g., phenytoin), and hypothyroidism. Melasma can generate psychological distress and might last for decades. Hence, it is very important to discuss with patients who have melasma that the condition is chronic. For this reason, patients should understand the proposed treatment strategy and its necessary incorporation into their daily skin care regimen. Treatment is challenging and comprises a variety of approaches in order to halt, obstruct, and/or preclude steps in the pigment production process (including melanocyte hyperactivity). The hyperactive (abnormal, highly metabolic, and easily triggered) melanocytes are located in the epidermis and/or dermis. Other modalities use the breakdown of deposited pigment for internal removal or external release, the exfoliation of cells to promote turnover, and the reduction of inflammation. The combination of topical therapy with other procedures might improve results. Such procedures include intense pulsed light (IPL), chemical peels, fractional nonablative lasers, lasers typically used for the removal of pigment (e.g., micro-, nano- and pico-second lasers), radiofrequency energy, and microneedling. Some treatments for melasma have been shown to be more effective than others. A more than 50-percent clearance of melasma after one month was demonstrated in a recent study that examined the value of a low-fluence Q-switched neodymium-doped yttrium aluminum garnet laser treatment (1.6–2J/cm 2 ) applied immediately after microdermabrasion (MCD) in combination with vitamin C or hydroquinone and tretinoin. 3 In a split-face study of 25 patients, the 1,927nm thulium fiber fractional laser has also been shown to improve melasma histologically. 4 However, treating melasma remains a challenging task. Other studies have presented mixed conclusions, 5 and interpreting the results of these studies can be hampered by their short durations of follow-up. Studies of a longer-term nature are required to evaluate long-term treatment efficacy and adverse effects. In any case, melasma appears to be a chronic condition, and thermal laser treatment might even exacerbate it. Thus, when considering these treatments, caution must be exercised. Melanin is essential to preventing skin damage, especially damage caused by ultraviolet (UV) light. A pathological increase in melanin production can result from overexposure to UV radiation. Other UV-related dermal and epidermal effects have been described thoroughly so far. 6 Classical A B S T R A C T Overview. Melasma is a resistant, sun-induced facial hyperpigmentation capable of remaining present for decades with ensuing psychological distress. Treatment is difficult and focuses on an array of measures to reduce skin hyperpigmentation resulting from triggered hyperactive melanocytes. The pathogenesis of melanoma is not clearly understood but it has been reported that some growth factors and specific cell-signaling pathways are involved. Objective. The objective of the current study was to evaluate the use of pulsed photobiomodulation to modulate melasma via the regulation of gene expression pertaining to skin pigmentation. Methods. We evaluated a two-step approach via a spilt-face pilot study involving seven patients with bilateral dermal melasma who had formerly undergone unsuccessful treatments. During treatment, the initial mobilization phase with microdermabrasion was closely followed by the modulation phase, delivering low-energy pulsed photons (940nm) to downregulate highly metabolic melanocytes in the dermis. A weekly treatment was performed for eight consecutive weeks. White light pictures, ultraviolet pictures, melanin index scores, and Melasma Area and Severity Index scores were obtained at baseline and at Week 12. Results. The pulsed photobiomodulation-treated side versus the control side showed statistically significant results for pigment reduction. Conclusion. This pilot study shows that dermal melasma can be significantly improved with pulsed photobiomodulation. Interestingly, it might also precondition the skin, helping it to build a resistance to future solar ultraviolet ray exposure. KEYWORDS: Photobiomodulation, Low level laser therapy, LLLT, melasma, chloasma, laser, photoprevention, sun, hydroquinone, sunscreen Dual Effect of Photobiomodulation on Melasma: Downregulation of Hyperpigmentation and Enhanced Solar Resistance—A Pilot Study by DANIEL BAROLET, MD, FRCPC Dr. Barolet is with the Department of Medicine, Dermatology Division, McGill University in Montreal, Québec, Canada, and with the RoseLab Skin Optics Laboratory in Laval, Canada. J Clin Aesthet Dermatol. 2018;11(4):28–34 FUNDING: No funding was provided for this article. DISCLOSURES: The author has no conflicts of interest relevant to the content of this article. CORRESPONDENCE: Daniel Barolet, MD, FRCPC; Email:

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