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Coming off the heels of summer sun and heat, for many, skin is left irritated, sensitive and exposed to an environment that tends to increase pigmented lesions. In nature, the intense summer sunlight plays a role in creating beautiful varicolored autumn leaves, but on our faces or skin, it can cause unpleasant mottled pigments. And when left untreated, the affected area will become much darker. Now, in fall, many patients have visited our clinic to treat pigmentation like melasma.
Melasma is an acquired pigmentary disorder that appears on both sides of the face, primarily on the forehead, malar areas and chin as diffuse and symmetrical grayish-brown patches in various sizes. It is distributed in different layers of the skin from the deep dermis to superficial epidermis, and although the exact cause has not been clearly identified, multiple factors including genetics, pregnancy, hormones, ultraviolet rays and stress, have been related to onset of these lesions.
Due to this, it remains difficult to make a full recovery and there are high recurrence rates. To prevent unexpected side effects and minimize risk of rebound pigmentation, treatment should comprise a combination of modalities that are safe and do not cause further irritation.
In our clinic, we mainly use laser toning to treat melasma and pigmented lesions. Multiple passes of low-fluence laser light at 1064 nm via a large spot size leads to gradual improvements.
My choice for laser toning is PICOCARE®, an FDA-cleared versatile, multi-application picosecond Nd:YAG laser from WonTech Co., Ltd. (Daejeon, South Korea). PICOCARE’s ultra-short pulse duration and high peak power enable more effective and safer treatment with lower pain and shorter downtime than conventional Q-switched nanosecond lasers.
PICOCARE features four complementary wavelengths of 532 nm, 595 nm, 660 nm and 1064 nm for numerous indications. It also has various handpieces including Zoom, Collimation, HEXA MLA and Dye (595 nm and 660 nm) that facilitate treatment of a wide-range of dermatologic conditions, such as pigmentation, multi-colored tattoos, various types of scars and skin rejuvenation (improvement of enlarged pores, fine lines, uneven skin texture and tone).
Among these handpieces, HEXA MLA, a fractional handpiece consisting of multiple microlens array, enables focused laser light at the center of each fractionated micro- beam area and delivers high-power density into the tissue (epidermis and/or dermis). Unlike conventional ablative fractional lasers, which remove the entire epidermis, it leaves the skin's surface intact and enables basement membrane integrity.
The high-peak power pulses formed by PICOCARE with HEXA MLA create transient cavitation bubbles below the skin called laser-induced optical breakdown (LIOB). After this, neocollagenesis, neoelastogenesis and mucin formation are stimulated through the natural healing process, and dermal remodeling also occurs in the damaged area. As a result, skin rejuvenation effects are induced by improving the overall dermal environment.
Moreover, pigmentation can be more finely and safely fragmented, since a photomechanical effect is dominant rather than a photothermal effect due PICOCARE’s short pulse duration.
Based on these mechanisms, the laser toning using HEXA MLA is called MLA Toning. If you want to focus more on removing an over-abundance of melanin particles, you can try Pico Toning using the standard Zoom handpiece. Since melasma has complex dermal and epidermal pigments, many dermatologists recommend simultaneously removing unwanted pigmentation and improving the dermal environment of underlying skin health to manage melasma. This therapeutic strategy can be put into practice with the PICOCARE’s two toning techniques.
Based on my experience in managing facial melasma, I perform MLA Toning with a low fluence of 0.2 – 0.4 J/cm2 and a large, 7 mm spot size. For Pico Toning Iuseafluence of 1.0J/cm2 and an 8mm spot size over a course of three to six sessions. It takes a total of three to four passes until clinical endpoints, mild erythema and/or edema, are reached.
By the third treatment session the size of the pigmented lesions will be much smaller and after that, concentration is also lighter than baseline. To maximize the therapeutic results, I often combine the Toning techniques with injections of low- dose tranexamic acid or application of regenerative cosmeceutical ampoules that contain EGF, FGF, tranexamic acid, polydeoxyribonucleotide and poly- glutamic acid.
Toning has low adverse effects and promotes rapid healing because it creates vacuoles into the tissue, leaving untreated healthy skin without damage to the skin’s surface. For that reason, I treat melasma in short intervals of one to two weeks depending on the patient’s rate of healing.
After treatment, it is possible to return to daily life quickly since there is almost no hyperpigmentation or persistent redness.
Another remarkable advantage of PICOCARE is the improved outcomes in recalcitrant pigmentation like melasma that have not improved with conventional Q-switched nanosecond lasers. Less thermal damage and more photomechanical effects result in better or equivalent results than conventional lasers, in only half the sessions.
Melasma is caused by multiple complex factors, so, although the Toning techniques can be used alone, combination therapy with energy-based devices is recommended to induce synergistic effects.
The Genesis procedure, which irradiates a 1064 nm wavelength with long pulse durations, can help strengthen the dermis and reduce feeding vessels around the melasma. A 1927 nm thulium fractional laser is effective in removal of superficial pigmentations and overall brightening effects. Combining these devices enables targeting of different effects in the various layers of the skin. Consequently, combining MLA and Pico Toning and/or other procedures results in high patient satisfaction with clinical results.
Consistent treatment with various strategies can keep melasma controlled to near normal levels. PICOCARE’s unique properties and vast range of applications help not only make this possible, but build doctor-patient trust through excellent clinical results. My hope is that starting treatment early with PICOCARE will allow patients to escape the shadows of melasma.
About the authors
Yung-Tsung Huang, MD
Dr. Huang is director of the Sinan Aesthetic Clinic and Taipei chief resident at Taipei City Hospital (Taipei, Taiwan). He earned his medical degree at Taipei Medical University. He participated in a dermatology fellowship at New York University and an eye specialist fellowship at the University of California.