Mottled Hypopigmentation from Laser Toning in the Treatment of Melasma: A Catastrophic or Manageable Complication?

Abstract

Melasma is a common acquired pigmentary disorder and difficult to treat with a high rate of recurrence. Conventional methods in the treatment of melasma have drawbacks and limitations. The so-called "laser toning" treatment, which uses a collimated low-fluence 1,064 nm Q-switched neodymium-doped yttrium aluminum garnet laser, was introduced a few years ago for the treatment of melasma. Laser toning has attracted much popularity and attention, and has become a crucial method for treatment of melasma. Laser toning is now a mainstay for treatment and management of melasma, however some dermatologists have excessive concerns about the risk of hypopigmentation. This inordinate fear may have originated from a few studies which insisted that laser toning therapy has a high risk of hypopigmentation and should be considered as a second-line treatment, not a first-line treatment for melasma. In the current study, we suggest that hypopigmentation after laser toning is a preventable and controllable complication based on our clinical experiences and reviews of various literatures. Key words

Comparison of 1064 nm Q‐switched Nd: YAG laser and Jessner peeling in melasma treatment

“…16 Previous studies were performed to optimize Nd:YAG laser treatment pulse parameters such as fluence, spot size, pulse width. 17,18 In these studies under the head of 'laser toning/adjustment, it has been found that low fluence, high peak power, short width, top-hat beam mode 1064 nm Nd-YAG laser decreases especially number of stage IV melanosomes, reduces cell volume and number of dendrites, inhibits synthesis of proteins like nerve growth factor, tyrosinase, tyrosinase related protein (TRP-1), MSH which increase melanin level. 18,19 In a In addition, Nd-YAG was assessed as monotherapy or in combination with chemical peeling agents.…”

Current and New Strategies for Managing Non-Responders to Laser Toning in the Treatment of Melasma

“…In the previous article, we concluded that excessive concern and fear of laser toning are unwarranted. 6 Meanwhile, one may still wonder about the impact of using gentle parameters on the efficacy. In this article, we will discuss limitations of the current laser toning techniques and suggest various ways to overcome these limitations through literature review and our own clinical experience.…”

“…8 In other words, laser toning improves melasma not by lowering the melanocyte count but by reducing melanin, melanosomes and melanocyte functions. [6][7][8] In our previous article 'Mottled hypopigmentation from laser toning in the treatment of melasma: a catastrophic or manageable complication? ', we performed a systematic literature review of publications reporting the development of hypopigmentation after laser toning.…”

“…', we performed a systematic literature review of publications reporting the development of hypopigmentation after laser toning. 6 Some reports focused on the occurrence of hypopigmentation following laser toning treatments, with an estimated incidence of around 10% in the Asian population. This led to a growing concern about the risk of laser toning.…”

“…This new method has the benefit of minimizing thermal damage to tissues. 6 Laser toning reduces the number of melanosomes (particularly, stage IV melanosomes), and induces structural change in them. While it does not destroy melanocytes, it does reduce the volume and dendrite count of melanocytes.…”