As the pigmentary system yields its secrets, and pathogenic disease mechanisms are more intensely investigated and studied, therapeutic options for pigmentary disorders expand.
Once a pigmentary disorder has been diagnosed, the first step is to educate the patient about the condition. This is particularly important if the condition has a chronic nature that will require long-term follow-up, such as melasma.
Table 6 Clinical Parameters to Be Considered Before Using Lasers in the Hyperpigmented Patient Ethnicity
Medical and surgical history
History of hypertrophic scarring and keloid formation History of post-inflammatory hyperpigmentation Skin type (Fitzpatrick phototype)
Use of isotretinoin
Results of previous cosmetic procedures
Sun protection must be the primary preventive measure for all patients. In order for therapy to be successful, counseling patients on sun safety is crucial. A broad-spectrum sunscreen with sun protection factor (SPF) 30 and physical blockers containing titanium dioxide or zinc oxide are preferred. Sunscreens block the stimulatory effect of the sun on melanocytes, as well as the transfer of existing melanosomes to keratynocytes.
In general, therapy for pigmentary disorders must be disease-specific and designed for the individual patient. Due to the complexity of the pigmentary system and the many pathogenic mechanisms involved in most acquired pigmentary disorders, it is only logical to assume that attacking the pigmentary cascade at different levels with different compounds would be the most reasonable approach.
First-line treatment for conditions such as melasma and PIH is topical therapy with a dual – or triple-combination product. Triple combinations contain hydroquinone with a retinoid and a mild corticosteroid; dual combination products contain hydroquinone and a retinoid. In the presence of sensitivity to any of these ingredients, alternative bleaching agents such as kojic acid, azelaic acid, or a cosmeceutical herbal compound can be considered.
Physical therapies are also introduced early in the treatment program. These therapies might include chemical peels, dermabrasion, microdermabrasion, laser, or pulsed light (Table 5). While there is insufficient evidence to conclude that these therapies are indispensable, we feel they are synergistic and help with maintenance control. Their help with the prevention of PIH is an added benefit.
The most commonly used physical therapies are salicylic acid peels, glycolic acid peels, and Jessner’s solution. These are primarily superficial peels. Our success rate with these mild procedures used in combination with topical therapies and sunscreen is quite high.
We put all our patients on pre-procedure protocols with skin care products ranging from mild cleansers and moisturizers to products containing active ingredients such as glycolic acid, retinol, Kinerase, or one of the new growth factors (TNS vs. e. g.,). After the procedure, patients are followed closely, and skin care regimens are restarted about a week later.
Light therapies have recently been introduced. We use IPL for treating lentigos. We have not tried IPL on melasma, although several studies have reported success, particularly in Asian patients. IPL provides a more acceptable modality than lasers, as that there is less photothermal injury and, therefore, less risk of PIH in patients with melasma.
Pigment-specific lasers such as Q-switched Nd-Yag are used for isolated lesions such as lentigos, and are only used as a last resort in cases of recalcitrant melasma.
When all other measures have failed, combining topical therapies with procedures is a reasonable approach, especially in recalcitrant conditions. The wisdom of this approach is supported by a handful of trials, although solid evidence is lacking. It is possible that the combination of all available therapies could lead to more rapid and greater improvement and accelerated healing times while reducing the occurrence of PIH. Once their disease has been cleared, patients are always placed on maintenance therapy with a retinoid, a mild lightening agent such as azelaic acid, or a cosmeceutical agent (4,33,56).
The treatment of pigmentary disorders remains a challenge, as there are no standardized treatments for melasma, PIH, or pigmentation due to photoaging.
The clinical response to pharmacological monotherapy is frequently slow and, in some cases, suboptimal. Whenever possible, the use of a dual – or triple-combination product as a first approach is recommended. The combination of various pharmacologic agents with chemical peels, microdermabrasion, and/or pigment-specific lasers can lead to accelerated healing times and a more rapid and greater improvement, and can reduce the occurrence of PIH. These advantages may enhance compliance.
Scientific evidence exists for a few of the pharmacologic agents, but evidence supporting the use of chemical peels and microdermabrasion for pigmentation disorders is scarce. Lasers have specific uses in the treatment of isolated lesions such as lentigos. Some reports have shown success with light sources including IPL for the treatment of melasma in Asians, specifically dark skinned ones. Pigment-specific lasers should only be reserved for refractory cases.
In general, combining procedural therapy with pharmacologic therapy is logical, although scientific evidence is lacking. Where trials do exist, evidence supports the combination of modalities. The procedures can also improve or hasten the cosmetic results obtained from other conventional therapies.
The choice of therapeutic agents involves assessment of the risk-benefit profile, and regimens should be individualized to specific disease and patient characteristics, as mentioned in Table 6.
Our success rate in the treatment of pigmentary disorders is quite high with the above approaches. However, due to the chronicity of some of these disorders, constant follow-up, patient counseling, and use of sunscreens are critical for long-term improvement and maintenance of results.