37 Introduction Photoaged skin is, sometimes, accompanied with various types of pigmented lesions (melasma, seborrheic keratoses, senile lentiginosis, acquired epidermal melanosis, nevus pigmentosus and e.t.c.) It is difficult to obtain improvement of melasma compared to other types of pigmented spots. Due to inadvertent laser or photo light treatments, the melasma gets even worse after the treatment. Therefore, sometimes to treat photoaged skin with various types of pigmented lesions including melasma with laser therapy is not warranted. Although the exact pathogenesis is unknown, melasma is believed to be associated with a multifactorial etiology. Genetics, ultraviolet radiation, pregnancy, hormone therapies, stress and phototoxic drugs have been implicated in the pathogenesis of melasma 1,2) . In addition to the routine usage of broad-spectrum sunscreens, bleaching agents such as hydroquinone and tretinoin 2-4) , and chemical peels 5,6) have shown satisfactory results for patients with epidermal pattern melasma. Nevertheless, to treat epidermal pattern or mixed pattern melasma are sometimes not therapeutically Original Article Combination Treatment for Melasma with a Carbon Photoenhancer Suspension- assisted 1064-nm Nd:YAG Laser Peel A Case Report of Seven Japanese Patients Yushi Kawasaki 1) , Chieko Mori 2) , Yoshinori Shirono 2) , Seiji Kawana 3) 1) Department of Dermatology, Nippon medical school Chiba Hokusoh hospital 2) Shirono clinic 3) Department of Dermatology, Nippon medical school hospital Abstract Photoaged skin is, sometimes, accompanied with various types of pigmented lesions. It is difficult to obtain improvement of melasma compared to other types of pigmented spots. The object is to report our experiments performed on melasma in Japanese patients with Fitzpatrick skin type III and IV and aged in their 34 yrs to 51yrs by the combination treatment by a topical Carbon suspension-assisted Nd:YAG Laser Peel (C-YP) with hydroquinone, tretinoin, tranexamic acid 750mg. Seven Japanese women who had the combination treatment for melasma exclusively with a topical carbon suspension-assisted Nd:YAG Laser peel were selected retrospectively. Each patient had treated using following laser parameters: 1064-mm wavelength, 0.3 ms pulse duration, a pulse repetition rate of 7 Hz and 5-mm spot size and evaluated. All patients had some degree of melasma improved in area and severity. Postoperative peeled skin was not irritated. Persistent erythema was not observed. The total score of our evaluation was elevated in each case after C-YP treatment and no deteriorated case has been seen. C-YP treatment may make it possible to provide effective results to control melasma, though application needs to be chosen carefully. KEY WORDS: carbon photoenhancer suspension, melasma, 1064-nm Nd:YAG Laser, peeling Received: Mar 12, 2012 Accepted: Apr. 17, 2013 Published online: Jun. 30, 2013 satisfactory 7,8) . These days, Fraxel™ laser have been approved for improving the severity of melasma 9) . Laser toning by Q-switched YAG laser and a topical carbon photoenhancer suspension-assisted Nd:YAG Laser peel have been utilized for melasma 10) . But postoperative skin was irritated in some cases. persistent erythema, intraoperative pain were observed in some cases. Thus, how to control the melasma of epidermal pattern or mixed pattern, or the various types of pigmented lesions with melasma is still under challenging. The object is to report our experiments performed on melasma by the combination treatment with hydroquinone , tretinoin, tranexamic acid 750mg and a topical carbon suspension-assisted Nd:YAG laser Peel (C-YP). The purpose of this analysis is to clinically estimate efficacy and effectiveness of combination therapy with 0.3 ms Nd: YAG laser assisted with a carbon photoenhancer suspension, together with oral and topical medication and to investigate how to control photoaged skin with various types of pigmented lesions with melasma. Anti-Aging Medicine 10 (3) : 37-41, 2013 (c) Japanese Society of Anti-Aging Medicine Yushi Kawasaki, M.D. Ph.D. Department of Dermatology, Nippon medical school Chiba Hokusoh hospital Kamakari1715, Inzai, Chiba 270-1694, Japan E-mail: [email protected]
Transcript
37
IntroductionPhotoaged skin is, sometimes, accompanied with various
types of pigmented lesions (melasma, seborrheic keratoses, senile lentiginosis, acquired epidermal melanosis, nevus pigmentosus and e.t.c.) It is difficult to obtain improvement of melasma compared to other types of pigmented spots. Due to inadvertent laser or photo light treatments, the melasma gets even worse after the treatment. Therefore, sometimes to treat photoaged skin with various types of pigmented lesions including melasma with laser therapy is not warranted.
Although the exact pathogenesis is unknown, melasma is believed to be associated with a multifactorial etiology. Genetics, ultraviolet radiation, pregnancy, hormone therapies, stress and phototoxic drugs have been implicated in the pathogenesis of melasma 1,2). In addition to the routine usage of broad-spectrum sunscreens, bleaching agents such as hydroquinone and tretinoin 2-4), and chemical peels 5,6) have shown satisfactory results for patients with epidermal pattern melasma. Nevertheless, to treat epidermal pattern or mixed pattern melasma are sometimes not therapeutically
Original Article
Combination Treatment for Melasma with a Carbon Photoenhancer Suspension-assisted 1064-nm Nd:YAG Laser PeelA Case Report of Seven Japanese Patients
1) Department of Dermatology, Nippon medical school Chiba Hokusoh hospital2) Shirono clinic 3) Department of Dermatology, Nippon medical school hospital
AbstractPhotoaged skin is, sometimes, accompanied with various types of pigmented lesions. It is difficult to obtain improvement of
melasma compared to other types of pigmented spots. The object is to report our experiments performed on melasma in Japanese patients with Fitzpatrick skin type III and IV and aged in their 34 yrs to 51yrs by the combination treatment by a topical Carbon suspension-assisted Nd:YAG Laser Peel (C-YP) with hydroquinone, tretinoin, tranexamic acid 750mg.
Seven Japanese women who had the combination treatment for melasma exclusively with a topical carbon suspension-assisted Nd:YAG Laser peel were selected retrospectively. Each patient had treated using following laser parameters: 1064-mm wavelength, 0.3 ms pulse duration, a pulse repetition rate of 7 Hz and 5-mm spot size and evaluated.
All patients had some degree of melasma improved in area and severity. Postoperative peeled skin was not irritated. Persistent erythema was not observed.
The total score of our evaluation was elevated in each case after C-YP treatment and no deteriorated case has been seen. C-YP treatment may make it possible to provide effective results to control melasma, though application needs to be chosen carefully.
satisfactory 7,8). These days, Fraxel™ laser have been approved for improving the severity of melasma 9). Laser toning by Q-switched YAG laser and a topical carbon photoenhancer suspension-assisted Nd:YAG Laser peel have been utilized for melasma 10). But postoperative skin was irritated in some cases. persistent erythema, intraoperative pain were observed in some cases. Thus, how to control the melasma of epidermal pattern or mixed pattern, or the various types of pigmented lesions with melasma is still under challenging.
The object is to report our experiments performed on melasma by the combination treatment with hydroquinone , tretinoin, tranexamic acid 750mg and a topical carbon suspension-assisted Nd:YAG laser Peel (C-YP). The purpose of this analysis is to clinically estimate efficacy and effectiveness of combination therapy with 0.3 ms Nd: YAG laser assisted with a carbon photoenhancer suspension, together with oral and topical medication and to investigate how to control photoaged skin with various types of pigmented lesions with melasma.
Anti-Aging Medicine 10 (3) : 37-41, 2013(c) Japanese Society of Anti-Aging Medicine
Yushi Kawasaki, M.D. Ph.D.Department of Dermatology, Nippon medical school Chiba Hokusoh hospital
Kamakari1715, Inzai, Chiba 270-1694, Japan E-mail: [email protected]
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Nd:YAG Laser peel with a Carbon Suspension
PatientsNewly treated 426 patients in Shirono clinic (Shibuya-
ku, Tokyo, Japan) for skin pigmentation from 2006 April to 2007 Mars, by the combination treatment with hydroquinone, tretinoin, tranexamic acid 750mg and C-YP, we have excluded from our study group retrospectively: those who are receiving other types of laser treatment for melasma, during this experiment, such as Fraxel SR750 (Reliant Technologies, Mountain View, CA) as well as, those who have been receiving intense-pulsed light (IPL) therapies more than four times. Because four IPL therapies may have enough efficacy for photoaged skin with melasma without using C-YP treatment 11). And exclusion criteria included much more times by IPL therapies than by C-YP treatment even if they treated beyond four times. We decide the treatment according to clients' wish everytime they wish to be treated. So that if they don’t wish to be treated by which therapy we recommend, only seven cases were remained for this analysis. They varies from 34 to 51 years old, a mean age of 44; phototypes III-IV)
All cases had fol low-up than more than 4 month postprocedure. Informed written consent was obtained from all subjects.
Photoaged skin pattenWhen photoaged skin with melasma was treated, we, at
first, identify photoaged skin with melasma into two group: mixed( dermal melasma and spotty pigmented lesions) pattern, epidermal pattern melasma. Mixed pattern melasma is in case that total area involved, darkness, and homogeneity of melasma is not so severe and accompanied by multiple ephelides and/ or solar lentiginosis. Epidermal pattern melasma is in case that total area involved, darkness and homogeneity of melasma is severe accompanied by vague ephelides and/ or solar lentigines. 4 cases for epidermal pattern melasma and 3 cases for mixed pattern melasma were entried.
Materials and Methods
EquipmentDevice used was Nd: YAG laser, Genesis (Cutera,
Breisbane, CA) with a pulse duration of 0.3-microsecond (middle ranged) and a wavelength distribution: 1064nm at a f luence of 8-17 J/cm2 , a pulse repetition rate of 7 Hz and a fixed beam of 5 mm in diameter, based on previous clinical experience.
Procedure of carbon-enhanced Nd:YAG laser peeling
The procedure is to administer 5000 counts of Nd:YAG laser at the energy of 15J – 17J /cm2, at the wavelength of Mid-Range with no gel to the target area. And after applying the carbon suspension gel on the targeted area of client face, then administer additional 500-700 counts at same ways at the energy of 8J – 11J / cm2 until carbon gel is completely peeled.
Evaluation CriteriaMelasma was evaluated at the baseline and at 4-9 months
(a mean month of 7) according to Melasma Area and Severity Index (MASI) 12). The severity of the melasma and pigmented lesions in each of these four regions was assessed based on three variables: percentage of total area involved (A), darkness (D), and homogeneity (H). The darkness of the melasma (D) compared to the normal skin and the homogeneity of the hyperpigmentation of the melasma (H) were estimated, 1 = barely visible hyperpigmentation/specks of involvement; 2 = mild hyperpigmentation/small patchy areas of involvement <1.5cm diameter; 3 = moderate hyperpigmentation/patches of involvement> 2cm diameter; 4 = severe hyperpigmentation/uniform skin involvement without any clear areas). We have utilized these three criteria above to score treatments as follows: very effective (+2), somewhat effective (+1), no change (0), worse (–1). Evaluations have been made according to the total score (Table 1).
Table 1 Evaluation Criteria
Very effective
Somewhat effective
No change
Worse
(+2)
(+1)
(0)
(–1)
ResultsEfficacy was estimated for size of pigmented patch, skin
color darkness and the homogeneity of the hyperpigmentation of melasma in each cases (Table 2).
Table 2 Efficasy
age pattern involved darkness homogeneity total
case 1
case 2
case 3
case 4
case 5
case 6
case 7
34
47
42
41
46
50
51
2
1
1
0
2
0
2
2
0
1
1
2
1
2
2
1
1
1
2
0
2
6
2
3
2
6
1
6
epidermal
epidermal
mixed
mixed
epidermal
mixed
epidermal
score indicates increased score*epidermal indicates epidermal pattern of melasma*mixed indicates mixed pattern of melasma: dermal melasma and spotty pigmented lesions*involved indicates area involved by melasma
Case 1: 34-aged woman with epidermal pattern melasma revealed+2 in skin color darkness, +2 in size of pigmented patch and +2 in homogeneity; totally +6 scored up in 8 months after 3 session (Fig.1). Case 2: 47-aged woman with epidermal pattern melasma revealed no change in skin color darkness, +1 in size of pigmented patch and +1 in homogeneity; totally
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Nd:YAG Laser peel with a Carbon Suspension
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+2 scored up in 9 months after 13 sessions (Fig.2). Case 3: 42-aged woman with mixed pattern melasma revealed+1 in skin color darkness,+1 in size of pigmented patch and +1 in homogeneity; totally +3 scored up in 4 months after 5 sessions. Case 4: 41-aged woman with mixed pattern revealed+1 in
skin color darkness, no change in size of pigmented patch and +1 in homogeneity; totally +2 scored up in 6 months after 8 sessions (Fig.3). Case 5: 46-aged woman with epidermal pattern melasma revealed+2 in skin color darkness, no change in size of pigmented patch and +2 in homogeneity; totally +4
1-A 1-B
1-C 1-D
Fig. 1. Digital photography at baseline (A, C, D) and month 8 (B) of a 34-year-old woman with epidermal pattern melasma in the treatment group (case 1).The combination treatment with hydroquinone and tretinoin with tranexamic acid 750mg had been done all over the face after 3 session of a topical carbon suspension-assisted 1064-nm Nd:YAG Laser peel in 8 months, so that total area of the skintone got brighter after the treatment. Procedure is to administer 5000 counts of Nd:YAG laser at the energy of 15J – 17J /cm2, at the wavelength of mid-range with no gel to the target area. And after applying the carbon suspension gel on the targeted area of client face, then administer additional 500-700 counts at same ways at the energy of 8J – 11J / cm2 until carbon gel is completely peeled.
2-A 2-B
Fig. 2. Digital photography at baseline (A) of a 47-year-old woman with epidermal pattern melasma in the treatment group and at month 6 (B) after 13 sessions in 9 months (case 2). The involved area and the homogeneity was somewhat improved in both the bilateral temporal areas and the upper forehead area.
40
Nd:YAG Laser peel with a Carbon Suspension
scored up in 6 months after 8 sessions. Case 6: 50-aged woman with mixed pattern melasma revealed+1 in skin color darkness, no change in size of pigmented patch and +0 in homogeneity; totally +1 scored up in 8 months after 11 sessions. In this case, hydroquinone and tretinoin were not utilized because of the client’s wish. Case 7: 51-aged woman with epidermal pattern melasma revealed+2 in skin color darkness, +2 in size of pigmented patch and +2 in homogeneity; totally +6 scored up in 8 months after 5 sessions. Postoperative peeled skin was not irritated. postoperative pain, hypopigmentation, persistent erythema, and scarring were not observed.
DiscussionIn case of the patients with resistant melasma, the
treatment by only oral and topical medication took too long, so that the clients most likely to discontinue the treatment on the halfway. On the other hand, the dermal peeling by C-YP treatment revealed visible efficacy so that it likely lead them to continue the treatment for melasma longer. Then the skin color darkness and homogeneity were once improved, that yields better percentage of keeping the treatment for melasma and leads better results. Actually, they requested to be treated by C-YP repeatedly than other laser treatment or IPL therapies.
A
In case 3. 42-aged woman with mixed pattern melasma was followed by only 4 months and revealed totally +3 scored up. And in case 6, 50-aged woman with mixed pattern melasma revealed+1 in skin color darkness and no change in size of pigmented patch and in homogeneity; totally only +1 scored up in 8 months after 11 sessions, though other cases with mixed pattern melasma showed the average +2.5 scored up. In this case, hydroquinone and tretinoin were not utilized because of the client’s wish. Indeed, the results of the average score of mixed pattern melasma is smaller than that of epidermal pattern
melasma, the low score in case 6 may suggest hydroquinone and tretinoin have the great role in the combination treatment with hydroquinone, tretinoin, tranexamic acid 750mg and C-YP treatment. After C-YP treatment, hydroquinone may permeates even more.
BWhen carbon in photoenhancer suspension absorb laser
energy and help the destruction of the epidermal melanin-containing structures, photoaged epidermis and thickened cornifications above will be removed. After that, topical hydroquinone on the target may work even more.
Especially, in case of epidermal pattern melasma, the size of pigmented patch, skin color darkness and homogeneity of the hyperpigmentation on the involved area are improved by C-YP treatment, and then, persistent solar lentiginosis may be able to be easily cleared by IPL therapies.
CIn case 2. some improvement of pigmented lesions of
epidermal pattern melasma with C-YP treatment were achieved even after no improvement have been seen by undergoing several IPL therapies. On the otherhand, we have observed some cases of melasma showing improvement with only IPL therapies in our experiences. We have not performed control study in this experiment. However, we have the impression that it’s easier to control melasma with C-YP treatment than with IPL therapies and actually, the clients wished to be treated by C-YP repeatedly than other laser treatment or IPL therapies.
1064-nm Nd:YAG laser works in two ways for eliminating epidermal melanin . The f irst is selective thermolysis. Hemoglobin has a strong absorption peak just below 1000nm. 1064-nm pulse created enough heat to provide selective thermolysis of vascular tissue in the papillary dermis, reaching vessels too deep to be addressesd by photo therapy. The second mechanism of action is through collagenosis. The microsecond pulse creates a temperature increase of 5-8°C in the papillary dermis. This is enough to stimulate cytokine release a bring fibroblast to the site over the seven to ten days 13). When
3-A 3-B
3-C
Fig. 3. Digital photography at baseline (A, B) and month 6 (C) of a 41-year-old woman with epidermal pattern melasma in the treatment group after 8 sessions in 6 months (case 4). The skin color darkness, the homogeneity and the size of pigmented patch was somewhat improved in both malar prominence areas. Post inflammation on left cheek was appeared after nevus was removed by Q-switched Ruby laser.
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Nd:YAG Laser peel with a Carbon Suspension
41
thermal injury is limited to the dermis, the desired effect of stimulating dermal collagen production and remodeling can be accomplished while avoiding the unwanted consequences of dermal injury. Thus, epidermal melanin will be eliminated with the faster epidermal remodeling and melasma will get improved better and faster.
DAnd then, a topical carbon photoenhancer suspension may
assist another role for melanin elimination in the epidermis. Normal type laser provide heterogeneous melanin destruction and excessed inflammation in the center of the target because of the gradient power of laser energy in the target.
Recently, novel medical devices also have been utilized for controlling the toning of melasma 9,10). Especially, top-hat typed Q-switched Nd:YAG laser which provide homogeneous melanin destruction revealed good efficacy to treat melasma.
A carbon photoenhancer suspension-assisted 1064-nm Nd:YAG laser may work as same way as top-hat typed Q-switched Nd:YAG laser do when laser absorption is dispersed by the carbon on the epidermis.
Fraxel TM laser also have been utilized, but, Fraxel TM laser treatment which provide heterogeneous melanin destruction sometimes cause post inf lammatory hyperpigmentation in dark skin types 9). Erythema and pain after Fraxel TM laser treatment is uncommon. they may be persistent for 4-5 days.
On the otherhand, in mixed pattern melasma, the size of pigmented patch was almost no changed in Case 4 and in Case 6. These results may suggest that C-YP treatment have slight effect to the size of pigmented patch of mixed pattern melasma, though it revealed effectiveness to some extent both in color darkness and in homogeneity of the skin.
ConclusionThe total score of our evaluation was elevated in each case
after the application of treatment and no deteriorated case has been seen.
Especially in the case of epidermal pattern melasma, the total score was higher than that in mixed pattern melasma. We assume that C-YP treatment makes it possible to provide effective results to control the skin color darkness of melasma with the combination treatment with hydroquinone, tretinoin, tranexamic acid 750mg and carbon-enhanced Nd:YAG laser peeling, though application needs to be chosen carefully.
Disclosure of Potential Conflicts of InterestKawasaki Y, Mori C, Shirono Y, Kawana have indicated
no significant interest with commercial supporters and declare other conflict of interests in the writing of this paper.
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