Retrospective analysis of the treatment of melasma lesions exhibiting increased vascularity with the 595‐nm pulsed dye laser combined with the 1927‐nm fractional low‐powered diode laser

Background Melasma presents a significant challenge to laser surgeons. Aggressive treatments often result in rebound melasma or post‐inflammatory pigmentary alteration. Recent reports suggest melasma pathogenesis may have a vascular component. Spectrocolorimetry can detect subtle or sub‐clinical telangiectatic erythema within melasma lesions. For certain patients identified by spectrocolorimetry, effective melasma treatment may include vascular‐targeted therapy together with pigment‐specific treatment modalities. Such combined therapies may reduce the likelihood of melasma recurrence. Objective To evaluate the efficacy of treating melasma lesions exhibiting subtle or sub‐clinical telangiectatic erythema with the 595‐nm pulsed dye laser (PDL) combined with the 1927‐nm fractional low‐powered diode laser (FDL). Methods A retrospective review was performed over a 2‐year period as follows. Evaluated patients ( n  = 11) include 10 women and 1 man, average age of 38.7 years, and Fitzpatrick skin types II–IV. Each patient exhibited melasma lesions with subtle or sub‐clinical telangiectatic erythema identified by spectrocolorimetry. Each underwent a series of treatments (average of four) at approximate 4–6 week intervals of the PDL followed by the FDL. Treatments were performed same‐day, sequentially, with 10–15 minute interim time allowance for skin cooling. The following PDL parameters were utilized: 10 mm spot, 10–20 ms pulse duration, 7.5–8.5 J/cm 2 fluence, 30/30 DCD. Eight passes with the FDL (Clear + Brilliant ® Permea™, Solta Medical, Hayward, CA) were then performed utilizing a “low” treatment level. Clinical endpoint was mild erythema and edema. Patients were encouraged to practice strict photoprotection and apply topical skin lightening agents, but compliance was not measured. An independent physician evaluated photographs taken at baseline and at follow‐up after last treatment session (average follow‐up of 96 days). A quartile improvement score was used to grade the improvement of melasma and underlying telangiectatic erythema. At time of data analysis, patient satisfaction was self‐graded on a three‐point scale (0 = not satisfied, 1 = satisfied, 2 = very satisfied). Results Six out of eleven patients (54%) demonstrated greater than 50% improvement in melasma presentation. Improvement in melasma generally paralleled improvement in erythema. No rebound melasma, post‐inflammatory changes, or adverse events were noted. Patient satisfaction responses averaged 1.6, with all (10) patients reporting 1 “satisfied” or 2 “very satisfied.” Conclusions Melasma lesions exhibiting subtle or sub‐clinical telangiectatic erythema may be improved by combined vascular‐targeted laser therapy together with fractional low‐powered diode laser therapy. A parallel improvement in telangiectatic erythema suggests a relationship between the underlying vasculature and hyperpigmentation. There is a low risk of adverse effects and overall patient satisfaction is high. Follow‐up to optimize treatment parameters and determine long‐term durability is needed. Lasers Surg. Med. 49:20–26, 2017. © 2016 Wiley Periodicals, Inc.