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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29 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 phototherapy using UVB radiation has been used to treat a wide range of dermatological conditions, including psoriasis. Less energetic photons of the electromagnetic spectrum, such as visible and near-infrared wavelengths, have been used successfully in photobiomodulation (PBM) without UV-induced side effects. This light therapy, which employs lasers and light- emitting diodes (LEDs), has been used to treat various medical conditions. 7 The light that LEDs emit is noncoherent and quasimonochromatic with a narrow bandwidth (±10nm). 8 Mounted in arrays, the incident energy densities are clinically useful, irradiating large surface areas (i.e., large spot sizes). 9 Certain skin diseases like acne vulgaris and skin ulcers have been ameliorated using LED phototherapy. 10 Skin conditions involving UV-related damage, including photoaging, have also shown improvement following LED treatment, 11,12 suggesting that LED treatment might reverse UV-induced injury. However, the effect of LEDs in downregulating melanogenesis has rarely been mentioned. In this study, we propose a two-step approach to treat melasma. First, in the mobilization phase, we precondition lesional melasma skin with mechanical MCD to open an epidermal window for the coming PBM photons. This is closely followed by the modulation phase, during which low-energy pulsed photons are delivered to downregulate—via specific cell signaling pathways—highly metabolic dermal melanocytes in melasma. MATERIALS AND METHODS Study participants. This was a split-face study involving seven female patients (mean age: 38 years) with bilateral dermal melasma. They all had previously undergone unsuccessful treatments using traditional topicals such as hydroquinone 4%, triple-fixed combination creams, and chemical peels (Table 1). No prior laser or IPL treatments had been performed on these subjects. Microdermabrasion device. To prepare the skin (mobilization phase), we employed an MCD device containing aluminum crystals (Megapeel; DermaMed Solutions, Lenni, Pennsylvania) using one pass at 57kpa on all facial melasma lesions, bilaterally. The rationale to use it prior to light-based (i.e., LED) treatment was two- fold: remove the stratum corneum to reduce undesirable photon reflection and mechanically activate a mild tissue response (dynamic response) including melanophage mobilization. Photobiomodulation light-emitting diode device. A high-power LED device emitting 940nm (bandwidth±10nm) was used (Lumiphase IR; OpusMed, Montreal, Canada) for the modulation phase. The ergonomic shape of the treatment head was optimal to keep a constant 2.5cm distance between the LED light source and the facial skin. A feature of the device allowed for half-face treatment coverage (illumination of 12.5cm x 20cm) and sequential pulsing. The irradiance was 90mW/cm 2 with a treatment duration of five minutes using a sequential pulsing code with a duty cycle of 50 percent, resulting in a total fluence of 13.5J/cm 2 . Procedure. MCD was performed bilaterally. Five minutes after MCD was performed, randomly assigned, patient-blinded, unilateral PBM light-based treatment was performed. The PBM light-based treatment was invisible and painless so the patient was not aware of the treatment side. A weekly treatment of MCD and PBM was performed for eight consecutive weeks. White light and UV pictures, melanin index scores (CM-600d Spectrophotometer; Konica Minolta, Tokyo, Japan), and Melasma Area and Severity Index (MASI) 13 scores were obtained at baseline and at Week 12. The before and after photographs (at baseline and Week 12, respectively) were evaluated by a panel of three independent observers. Follow-up visits were scheduled at baseline and at Week 12 (n=7) and at up to 12 months post-treatment (n=3). Statistical analysis. This split-face study (the patients were their own controls) compared the MCD plus LED-treated side to the MCD- only treated side (control side). For every measurement (4-point scale, MASI and melanin index), data were analyzed using analysis of variance, with p<0.05 set as the level of significance. RESULTS Four-point scale evaluation. A panel of three physicians evaluated randomly assigned before and after pictures using a standard 4-point scale measurement method to determine the percentage of improvement. The PBM-treated side versus the control side showed statistically significant results for pigment reduction (Figure 1). MASI. MASI score is a tool to evaluate the severity of melasma. To calculate the MASI score, the sum of the severity grade for darkness (D) and homogeneity (H) was multiplied by the numerical value of the areas (A) involved and by the percentages of the four facial areas (10–30%). Total MASI score was as follows: forehead 0.3 (D+H)A + right malar 0.3 (D+H)A + left malar 0.3 (D+H)A + chin 0.1 (D+H)A. The PBM-treated side over time went from 11.4 to 4.7 at Week 12 (p<0.001) (Figure 2). Melanin index. Although clinical improvement was clearly noticeable in the TABLE 1. Patient demographics (n=7) PATIENT AGE (YEARS) SEX DIAGNOSIS TREATMENT SITE PRIOR UNSUCCESSFUL TREATMENT(S) 1 40 F Melasma Forehead/cheeks None 2 36 F Melasma Forehead/cheeks/upper lip/chin Hydroquinone cream 3 25 F Melasma Glabella/cheeks/upper lip/chin Hydroquinone cream 4 42 F Melasma Forehead/cheeks/upper lip/chin Hydroquinone cream, Kligman 5 42 F Melasma Cheeks Hydroquinone cream 6 34 F Melasma Forehead/cheeks/chin Hydroquinone cream 7 48 F Melasma Cheeks Hydroquinone cream, Kligman, chemical peel Kligman: compounding cream

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