Among laser and light-based technologies, there are numerous options available that can effectively treat facial dyschromia. Achieving a successful outcome and patient satisfaction, however, also depends on appropriate diagnosis and appreciation of potential risks, explains Paul J. Carniol, M.D.
Speaking at the Art of Cosmetic Laser Surgery, a workshop preceding the 27th annual scientific meeting of the American Academy of Cosmetic Surgery, Dr. Carniol defines dyschromia as any skin-pigment variation, including hyperpigmentation, hypopigmentation and melasma. He discussed considerations for patient evaluation and education and the role of intense pulsed light (IPL), photodynamic therapy (PDT) and various lasers (532 nm, erbium:YAG, CO2 fractionated resurfacing).
OPTIMIZING SAFETY, SATISFACTION One of the key concerns in treating a discrete pigmented lesion, particularly solar lentigines, is that they often exist against a background of diffuse photodamage. Therefore, treatment to clear only the lesion itself may leave a hypopigmented spot and dissatisfied patient, says Dr. Carniol, clinical professor, department of surgery, New Jersey Medical School, Newark, and in private practice specializing in cosmetic, laser and reconstructive plastic surgery, Summit, N.J."For this reason, I usually avoid treating facial lentigines in an isolated manner, except in young people," he says. "For patients with diffuse photodamage, it is better to treat a broader area, at least the facial subunit, rather than just the localized pigmentation."
Obtaining good preoperative photographs is also important for documenting improvement to the patient, as the treatment will likely significantly improve the dyschromia but may not clear it completely.
Cosmetic surgeons should also be cautious about the diagnosis. Pitfalls include missing the diagnosis of malignant melanoma in patients with a melanocytic lesion or lupus in individuals who present with diffuse facial erythema. In addition, in patients who present with multiple café-au-lait spots, the possibility that these lesions are a feature of an underlying syndrome should be considered so that an appropriate evaluation is performed.
If there is any suspicion that a melanocytic lesion is a malignant melanoma and not benign, Dr. Carniol advocates obtaining a 2.0 mm punch biopsy for evaluation by a dermatopathologist, targeting the most worrisome-looking part of the lesion.
"Malignant melanoma may develop with an initial radial growth phase and can masquerade as a lentigine. You don't want to miss the diagnosis and treat a malignant melanoma with a laser," he says.
He acknowledges that although there are also amelanotic melanomas to consider and that a full shave or excisional biopsy is preferred for diagnosis when there is a strong suspicion of melanoma, a punch biopsy sent for expert review by a skilled dermatopathologist is reasonable if the surgeon is confident that the lesion is benign.
MINDING MELASMA When it comes to treating melasma, a variety of modalities can be used to clear the hyperpigmentation. However, Dr. Carniol says, because melasma tends to recur, he will refuse to perform the procedure unless he is convinced the patient will adhere to the need for strict sun avoidance. This is critical to preventing melasma recurrence, he says.
Patients are advised about avoiding intense sun exposure and the need for daily use of a high-SPF, broad-spectrum sunscreen that provides both UVA and UVB protection. In addition, Dr. Carniol says he advises patients that melasma can increase after laser/light treatment and that they should consider this carefully before being treated.
"I tell patients that if they are not going to comply with sun avoidance, laser treatment is a waste of time and money. I find it is better to refuse treatment than deal with patients dissatisfied because of recurrent pigmentation due to sun exposure," Dr. Carniol says.