Disorders of hyperpigmentation. Part II. Review of management and treatment options for hyperpigmentation.

Key challenges in the management of pigmentary disorders such as melasma and postinflammatory hyperpigmentation are their resistance to treatment, tendency to recur after treatment, and the risk of exacerbating hyperpigmentation with many treatment modalities. The second article in this 2-part continuing medical education series on pigmentary disorders focuses on the evidence behind medical and procedural treatments of dyschromias, including photoprotection, topical lightening agents, oral agents, chemical peels, and laser therapy.

Lasers' Q-switched treatment in skin and subcutaneous lesions - review.

The numerous medical fields like dermatology, ophthalmology and surgery widely use laser therapy including Q-switched lasers. This review aims to provide information on the application and effectiveness of Q-switched lasers in dermal and vascular lesions. Q-switched lasers play a crucial part in the athlete's foot treatment and onychomycosis both in mono- and polytherapy. Laser therapy remains the gold standard for tattoo removal. Additionally, laser therapy shows high effectiveness in melasma, telangiectasias and photoaging therapy. The ability to adjust precise laser parameters like length or beam energy provides tight control of the treated area, significantly reducing the risk of adverse effects.

Comparing the efficacy and safety of Q-switched and picosecond lasers in the treatment of nevus of Ota: a systematic review and meta-analysis.

Nevus of Ota is cosmetically burdensome and often prompts patients to seek treatment. Lasers are commonly used in removing these lesions; however, no systemic analysis has been conducted to support a gold standard laser. To conduct a meta-analysis of the efficacy and safety of Q-switched Nd:YAG lasers (QSNL), Q-switched ruby lasers (QSRL), Q-switched alexandrite lasers (QSAL), and picosecond alexandrite lasers (PSAL) in removing nevus of Ota. Inclusion criteria were nevus of Ota patients treated with QSNL, QSRL, QSAL, or PSAL and documentation of percent clearance and the rate of at least one adverse event. Articles in English, Chinese, or Japanese were included. The prespecified outcome measures were efficacy (percent clearance) and safety (rates of hyperpigmentation, hypopigmentation, scarring, and recurrence). The review included 57 studies and 13,417 patients. The pooled success rate was 64% for QSNL (95% CI 52-76%), 54% for QSRL (95% CI 39-69%), 58% for QSAL (95% CI 44-72%), and 100% for PSAL (95% CI 98-102%). The pooled adverse event rate was 5% for QSNL (95% CI 4-6%), 14% for QSRL (95% CI 9-19%), 9% for QSAL (95% CI 6-12%), and 44% (95% CI 31-57%) for PSAL. QSNL has the most evidence for effectively and safely treating nevus of Ota. PSAL potentially has a superior efficacy; however, further studies are needed to elucidate its side effect profile when treating nevus of Ota.

Combined pulsed dye laser and Q-switched Nd:YAG laser intraumatic facial tattoo removal: A case series.

Traumatic tattoos can be treated with several methods, including mechanical and chemical devices. However, they are rarely used due to the high risk of permanent side effects such as scarring and depigmentation. Recently, laser devices, especially the Q-switched (QS) laser and the pulsed dye laser (PDL), applied in combination, have achieved complete clearance of the lesions without any risk of side effects. Herein, we reported three cases of traumatic facial tattoos successfully treated with combined PDL and QS Nd:YAG laser.

Laugier-Hunziker syndrome: complete clearance of mucosal lentigines with a single session of Q-Switched Nd:YAG laser.

Background: Laugier-Hunziker (LH) syndrome is a rare condition in which melanocyte overactivity produces lentiginous lesions of the lips and buccal mucosa. Objective: Given the paucity of reports on therapeutic options in LH syndrome, this case is herein reported to show the response to treatment with the Q-Switched Nd:YAG laser in a 32-year-old man with LH Syndrome. Methods: The Q-Switched Nd:YAG laser was used to treat the lentiginous lesions on the mucosal surface of the lower lips using a single pass at 532 nm. Results: There was complete clearance of the mucosal lentiginous lesions with a single laser session, and recurrence was not observed after 12 months. Conclusion: The Q-Switched Nd:YAG laser is an effective treatment option for cosmetic benefit in LH Syndrome.

A retrospective analysis of the influencing factors and complications of Q-switched lasers in tattoo removal in China.

BACKGROUND AND OBJECTIVE: Q-switched (QS) lasers are the gold standard for tattoo removal. The purpose of the present study was to gain a more comprehensive understanding of the factors that influence the efficacy of QS lasers and their associated complications in the removal of tattoos in China. PATIENTS AND METHODS: Clinical data of 266 patients were analyzed retrospectively. The tattoo clearance rate was evaluated using the 4-point scale. The Cox regression model was applied to analyze the factors that affected the efficacy of QS lasers in tattoo removal. In addition, treatment-related adverse reactions were analyzed. RESULTS: The results showed that several variables had a statistically significant effect (p < 0.05) on the efficacy of QS laser-mediated tattoo removal treatment, including the patients' age, the tattoo's age, type, color, or ink density and the number of treatments. A variety of adverse responses occurred during the laser treatment. The overall incidence of adverse responses was approximately 24.06%, including pigmentation, hypopigmentation, bulla formation, allergic reactions, and skin texture changes or hypertrophic scarring. CONCLUSION: Some factors may influence the efficacy of QS lasers in the treatment of tattoos and certain adverse reactions may occur during this process.

Impact of laser pulse duration on the reduction of intraocular pressure during selective laser trabeculoplasty.

PURPOSE: To evaluate the efficacy of selective laser trabeculoplasty (SLT) to lower intraocular pressure (IOP) in patients with primary open-angle glaucoma (POAG), normal tension glaucoma (NTG) or ocular hypertension (OHT), when performed with laser pulse duration of 1 ns compared with standard 3-5 ns. METHODS: Bilateral SLT with a 532 nm Q-switched neodymium-doped yttrium aluminium garnet laser was conducted in 30 patients (60 eyes) with POAG (n = 5), NTG (n = 2) or OHT (n = 23). Pulse duration was 1 ns in the right eye (30 eyes; cases) and 3-5 ns in all left eyes (controls). Main outcome measures were IOP at 1 h, 1 day, 8 weeks and 6 months, and the rate of adverse ocular tissue reactions in all eyes. RESULTS: Mean 1 ns and 3-5 ns SLT IOPs were 24.1 and 24.3 mmHg, respectively, at baseline. No statistically significant difference in mean 1 ns and 3-5 ns SLT IOP was observed at 1 h (P = 0.761), 1 day (P = 0.758), 8 weeks (P = 0.352) and 6 months postoperatively (P = 0.879). No significant difference in postoperative anterior chamber inflammation was observed between the eyes (P = 0.529). Treatment with both laser pulse durations resulted in minor ultrastructural changes in the drainage angle. CONCLUSIONS: SLT performed with a 1 ns laser pulse duration does not appear to be inferior to SLT performed with the standard 3-5 ns duration at lowering IOP in treatment-naïve patients with POAG, NTG or OHT.

A split-face, investigator-blinded comparative study on the efficacy and safety of Q-switched Nd:YAG laser plus microneedling with vitamin C versus Q-switched Nd:YAG laser for the treatment of recalcitrant melasma.

BACKGROUND: High recurrence has previously been reported in the treatment of melasma with low-fluence 1,064-nm Q-switched neodymium-doped yttrium aluminium garnet (QS-Nd:YAG) laser. On the other hand, the efficacy and safety of the QS-Nd:YAG laser plus microneedling with vitamin C have not been evaluated in patients with mixed-type melasma. MATERIAL AND METHODS: Sixteen patients with recalcitrant dermal- or mixed-type melasma were included in the study. One side of patients' face was treated with QS-Nd:YAG laser plus microneedling with vitamin C (Group A) and the other side with QS-Nd:YAG laser alone (Group B) for four sessions at four-week intervals. Melasma Area Severity Index (MASI) scores and clinician's evaluation of clinical response were assessed monthly. RESULTS: Group A had a significantly lower mean MASI score and better treatment response than Group B according to clinician's evaluation. According to MASI scores, in Group B, two patients had a good response while 12 were unresponsive to treatment. Good or very good improvement was reported by 10 patients in Group A and three patients in Group B. Adverse effects and recurrence rates were similar in Groups A and B (31.3 and 43.8%, respectively). DISCUSSION: QS-Nd:YAG increases the blood circulation in the dermis, thereby enhancing the mechanical effect of microneedling to promote the penetration of vitamin C. CONCLUSION: Vitamin C application with microneedling immediately after treatment with QS-Nd:YAG laser is a promising adjunctive method for the treatment of recalcitrant melasma.

Standard operating protocol for utilizing energy-based devices in aesthetic practice.

BACKGROUND: Lasers and other energy-based devices are increasingly becoming popular in aesthetic practice. Many centers employ doctors or technicians to perform these procedures where treating doctor and operating doctor may be different. Hence the need for standard operative protocols, to be followed while performing these procedures to avoid mistakes, complications and to get optimum results. In the current review article, group of doctors who have worked with these energy-based devices over many years worked together and suggested the protocols to be followed for the most commonly used energy-based procedures. AIM: To provide Standard operating protocols for the operator and staff to ensure, efficacy, safety, for the patient and for the devices. METHODS: The following protocols have been drafted based on the best practices followed by the authors in their clinics and reflect their consensus opinion. The objective is to provide operating protocols in a standard format, which can be of use by practicing dermatologists and their staff. The protocols include both general guidelines for the laser room and specific protocols for different machines. The draft follows the following schema: General instructions for all the energy-based devices. Specific protocols for different devices: Laser hair removal, fractional lasers, Q-switched lasers, fractional microneedling radiofrequency and cryolipolysis. CONCLUSIONS: The protocols proposed help to maintain the uniformity and avoid complications. However, these instructions are generalized and not machine or lesion specific. There may be variations in the protocols depending on the treatment lesion and treating doctor as well as machine.

Advancements in Laser Therapies for Dermal Hyperpigmentation in Skin of Color: A Comprehensive Literature Review and Experience of Sequential Laser Treatments in a Cohort of 122 Indian Patients.

The heightened awareness of ethnic dermatology aligns with the growing prevalence of skin of color communities globally, where hyperpigmentation disorders pose a common dermatological challenge. Effectively addressing dermal pigmentation is challenging due to its resistance to conventional therapies and its association with impaired quality of life. This underscores the need for effective treatments and a thorough grasp of laser advancements. A relevant literature search spanning the last 7 years across the PubMed database reveals core studies, challenges, and the evolution of laser technologies tailored for various forms of congenital and acquired dermal hyperpigmentation in skin of color. This comprehensive review explores the mechanisms, applications, and recommendations for pigmentary laser technologies, highlighting the key role of Q-switched lasers in their established millisecond/ nanosecond forms and emerging picosecond lasers, fractional non-ablative and ablative lasers, Intense Pulsed Light, etc. The summary of evidence includes studies on dermal melanocytosis (nevus of Ota and Hori's nevus), tattoos, acquired dermal macular hyperpigmentation, etc., and also entities with mixed epidermal-dermal components, such as melasma and post-inflammatory hyperpigmentation. The review offers valuable insights for clinicians to make informed decisions based on diagnosis, skin type, and the latest technologies to optimize results and minimize complications, especially in darker Fitzpatrick skin types. In their five-year study with 122 Indian patients, the authors applied specific laser combinations for diverse dermal melanoses, including tattoos, dermal/mixed melasma, acquired dermal macular hyperpigmentation, and dermal nevi. Substantial pigmentation reduction, subjectively assessed by both physicians and patients, was observed across all groups. A one-way ANOVA indicated a significant difference in mean improvement scores across various pigmentary conditions (F = 3.39, p = 0.02), with melasma patients exhibiting a significantly higher improvement score than tattoos (p = 0.03). The results affirmed the safety and efficacy of sequential laser therapy for dermal pigmentation in skin of color, advocating for flexibility in approach while maintaining the rationale behind the laser sequences. Despite advancements, challenges persist, and gaps in the current literature are identified. In conclusion, this summary highlights the ongoing pursuit of optimal protocols in dermatological laser treatments for dermal melanoses, offering valuable insights for future research and clinical practice.

Enhanced resolution optoacoustic microscopy using a picosecond high repetition rate Q-switched microchip laser.

Conventional optoacoustic microscopy (OAM) instruments have at their core a nanosecond pulse duration laser. If lasers with a shorter pulse duration are used, broader, higher frequency ultrasound waves are expected to be generated and as a result, the axial resolution of the instrument is improved. Here, we exploit the advantage offered by a picosecond duration pulse laser to enhance the axial resolution of an OAM instrument. In comparison to an instrument equipped with a 2-ns pulse duration laser, an improvement in the axial resolution of 50% is experimentally demonstrated by using excitation pulses of only 85 ps. To illustrate the capability of the instrument to generate high-quality optoacoustic images, en-face, in-vivo images of the brain of Xenopus laevis tadpole are presented with a lateral resolution of 3.8 µ m throughout the entire axial imaging range.

Single and combined 1064 nm Q-switched Nd: YAG laser therapy in melasma: A meta-analysis.

PURPOSE: This article attempted to describe the efficacy and safety of 1064QNYL in combination with other treatments for refractory melasma. METHODS: Two researchers independently retrieved randomized controlled trials (RCTs) according to inclusion and exclusion criteria. Primary outcome was evaluated with MASI and mMASI scores in control group and experiment group. The secondary outcome was evaluated with MI scores. We calculated 95% CI of standardized mean difference (SMD) and heterogeneity of the included literature by Higgins I2 test, and assessed publication bias by Funnel plots, Egger's, and Begg's tests. RESULTS: A total of 12 articles including 322 subjects were analyzed. Experiment group was treated with 1064QNYL combined with single treatment (e.g., PDL, IPL, RF, and TA). Control group was treated with 1064QNYL alone. A greater reduction of Melasma Area and Severity Index (MASI)/modified Melasma Area and Severity Index (mMASI) scores were shown in experiment group than that in control group at the end of the treatment (SMD, -0.37; 95% CI -0.70 to -0.04, p = 0.03, I2  = 33%). The SMD of MI scores further supported this conclusion by -0.32 (95% CI -0.63 to -0.02, p = 0.04, I2  = 27%). As for adverse events (AEs), combined treatment gave rise to more mild burning, stinging, and erythema that resolved spontaneously. Several studies reported focal purpura, punctate leukoderma, hyperpigmentation, hypopigmentation, and so on. CONCLUSION: Combined 1064QNYL treatment was better than single laser treatment, with the highest short-term benefit and long-term follow-up to maintain the effect in favor of combined treatment.

Efficacy of the combination of Q-switched Nd:YAG laser and microneedling for melasma.

BACKGROUND: Melasma is a common, multifactorial, and recurring disease which is not easy to treat. AIMS: The purpose of this study is to evaluate the efficacy of microneedling in combination with Q-switched neodymium-doped yttrium aluminum garnet laser (QsNd-YAG laser) for treatment of melasma. PATIENTS/METHODS: Fifteen female patients with epidermal or mixed-type melasma on the face were included in the study. Patients were first treated with QsNd-YAG laser, and then with microneedling containing mesotherapy products of biomimetic peptides, at the same session. Modified Melasma Area Severity Index (mMASI) scores were calculated before the first session and again 2 weeks after the last session. The same treatment protocol was repeated every 2 weeks for five sessions within period of 3 months of therapy. The evaluation was performed according to the before and after photographs taken from three angles including 90-degree front and 45 degrees from left and right with the VISIA device. RESULTS: Of the 15 patients included in the study, the mean mMASI scores before and after treatment were 9.2 ± 5.7 (3.8-23.1) and 3.6 ± 4.0 (0.6-16.8), respectively. mMASI scores were significantly reduced after completion of the protocol. Six (40%) patients had "very good response," 4 (26.7%) patients had "good response," and 5 (33.3%) patients were "unresponsive." Six (40%) patients were followed up for 1 year, and only 1 patient had a recurrence (6.7%). CONCLUSIONS: In addition to the use of photoprotective measures, multimodality treatment including QsNd-YAG laser and microneedling with mesotherapy products containing biomimetic peptides is effective to treat melasma and they work synergistically.

Treatment of Melasma with Pulsed-Dye Laser and 1,064-nm Q-Switched Nd:YAG Laser: A Split-Face Study.

BACKGROUND: Melasma is an acquired pigmentary disorder that is often therapeutically challenging. Recent evidence suggests that vascular abnormalities are involved in melasma pathogenesis. Pulsed-dye laser (PDL) is considered as standard therapy for vascular lesions. OBJECTIVE: To assess the efficacy of PDL combined with low-fluence Q-switched Nd:YAG laser (QSNY) in the treatment of melasma. METHODS: Seventeen melasma patients were enrolled in this study. All subjects were treated with a total of nine QSNY treatment sessions at one-week intervals. Three sessions of PDL were additionally performed immediately after QSNY treatment on the half of the face at baseline, week 4, and week 8. The melasma area and the severity index (MASI) score was calculated at the baseline, one week after the last treatment (week 9), as well as at the follow-up 8 weeks after the last treatment (week 16). Dermoscopic images at the baseline were classified as to whether the visibly widened capillaries were detected or not. RESULTS: MASI scores on the PDL+QSNY and QSNY side decreased significantly during the study period. There was no significant difference in the MASI score change between both sides in all periods. However, seven patients who had visibly widened capillaries on dermoscopy showed significant difference in both sides in terms of changes in the MASI score during treatment. CONCLUSION: PDL combined with QSNY may be considered as a safe and effective treatment for melasma patients who show visibly widened capillaries on dermoscopy.

Long-term results in low-fluence 1064-nm Q-Switched Nd:YAG laser for melasma: Is it effective?

OBJECTIVE: This study assessed the safety and clinical efficacy of a low-fluence 1064-nm Q-switched neodymium-doped:yttrium aluminum garnet (QS-Nd:YAG) laser in the treatment of patients with melasma. METHODS: The study evaluated 34 melasma patients treated at a single institution using a 1064-nm QS-Nd:YAG laser. The laser parameters were 6 mm spot size and 2.5 J/cm2 fluence with multiple passes for 6-10 (median 8) sessions at 2-week intervals. Outcomes were evaluated using photography, the modified Melasma Area and Severity Index (mMASI) score, and patient satisfaction interviews after the last treatment and 1 year after the last treatment. RESULTS: After the low-fluence 1064-nm QS-Nd:YAG laser treatments, the mean mMASI score decreased from 6.7 ± 3.3 to 3.2 ± 1.6 (P < 0.01). After treatment completion, 20 of 34 patients (58.8%) rated themselves as having at least a 50% reduction in melasma severity. One year after the last treatment, recurrence was observed in 20 patients (58.8%) and the mean mMASI score increased from 3.2 ± 1.6 to 5.8 ± 1.9 in all patients. CONCLUSION: The recurrence of low-fluence 1064-nm QS-Nd:YAG laser rates in melasma was high when the long-term results were considered. This result may be attributed to certain patient and treatment-related factors.

Long-term evaluation of ink clearance in tattoos with different color intensity using the 1064-nm Q-switched Nd:YAG laser.

OBJECTIVE: The aim of the study was to evaluate the efficacy of tattoo removal treatments using the 1064-nm Q-switched (QS) Nd:YAG laser. BACKGROUND DATA: Today, QS lasers appear to be the most common, effective, and safest methods to treat unwanted markings. MATERIAL AND METHODS: A total of 64 patients with 75 unwanted tattoos were enrolled in the study. Tattoo clearance was evaluated according to the color intensity - concentration of pigment: group I (34) - black; group II (41) - gray. Consideration included methods of tattooing and tattoo techniques. RESULTS: In group I, after the first treatment session the median of clearance was 30% (10-50%), while in group II, the median was 50% (40-70%). After the second treatment session, median in group I increased to 40% (30-50%). Median of group II increased to 70% (50-80%). The highest number of treatment in group I was 7. After that, the median grew to 75%, while the highest amount of treatment in group II was 5 and a median of 90% was achieved. CONCLUSIONS: Effects were dependent upon the amount of ink deposited in the tissue. Old amateur tattoos and tattoos containing small quantities of ink (technique: shading and lines) demonstrated the quickest and the most efficacious results. Tattoos with large quantities of ink, obtained by filling, required the greatest number of treatment sessions. The final outcome in tattoo clearing can only be assessed following treatment completion, which may in some cases take 2-3 years. Presumably, in some cases, complete clearance is impossible.