Treating Pigmentation

By Aesthetics journal / 01 Apr 2014

In the first of a two-part series on treating pigmentation, we ask a panel of practitioners to discuss the benefits of lasers and lights


Dr Harold Lancer (HL) Dermatologist and medical director at Lancer Dermatology
Dr Robin Stones (RS) Medical director at Court House Clinics for the North of England
Lauren Sibley (LS) Clinic manager and lead aesthetic practitioner at Juvea Aesthetics
Dr Sanjay Rajpara (SR) Consultant dermatologist and clinical lead at NHS Grampian Dr Maria Gonzalez (MG) Medical director and dermatologist at Specialist Skin Clinic 

What are the key patient groups seeking treatment for pigmentation in your practice?

HL: Pigmentation problems affect everyone from newborn babies to 90 year olds, with all skin types, and I see them all in my clinic. I have 30, 000 current patients.
RS: The most common presentations are ladies of all ages with melasma, and middle-aged and older people of both sexes with photodamage such as solar lentigines. Natural skin blemishes such as seborrhoeic keratoses are also common from middle age and onwards.
SR: Key patient groups for me are Asian, Middle Eastern, African and southern or eastern European and sometimes northern European Women. I also see some men with darker skin types aged 20-40 years. They want to have lighter skin as they think that having darker skin on the face and some other parts of their body is not normal. Somehow it is in the psyche of many people that only fair skin colour is normal, and media and cinema portrayal of the perfect skin tone and light coloured skin has not helped. In women and men of northern European descent and lighter skin types aged 50-70 years, it’s sun induced ageing related pigmentation on the face, hands, neck and upper chest.

Where does pigmentation rate on patients’ worry scale?

HL: Pigmentation is the number one concern of patients in my clinic. Much more than lines, wrinkles and sagging skin. People want to be the same colour from head to toe and they understand that a colour mismatch can give a more aged look.
LS: It is very common for patients to self-treat. It is amazing what you can buy on the internet. I had one patient who had bought a trichloroacetic acid (TCA) peel from the internet and put it on her skin. Of course that is very risky.
MG: Pigmentation causes quite a significant amount of distress among patients. I am seeing increasing numbers of younger patients, those in their early 20s, already showing signs of photodamage.

How do you counsel patients prior to treatment?

Alex TriVantage laser
Cynosure RevLite

HL: Pigmentation is the most difficult area in cosmetic medicine. I always see the patient first and start a treatment plan including skincare for the first two to four weeks. The most important thing to realise at this stage is that pigmentation disorders are different in different ethnic ancestries. And if you treat someone with Irish or Swedish ancestry you are likely to have a better result than if you treat someone with Spanish or Moroccan ancestry. Skin colour, eye colour and hair colour are truly unimportant. Ancestry will give you a better guide to who should be treated by what type of instrument, if at all. This is the basis of the Lancer Ethnicity Scale.
LS: Before any treatment for pigmentation I always take a complete medical history but it is also vital to understand the patient’s ethnic skin type. This is particularly important with patients who may be of Asian origin because Asian skin has a high epidermal melanin content, which can act as a competing chromophobe for pigment lasers and trigger post-inflammatory hyper pigmentation (PIH).
SR: Laser treatment has risks of hypo/hyperpigmentation, scarring and recurrence. Counselling is very important to explain these risks and weigh the risk/benefit ratio in individual patients. Often I see patients twice for consultation before deciding on any treatment option.
MG: All my patients have a 30 minute consultation before treatment is offered. Patients are never treated on the day of their consultation. All potential side effects and complications are discussed in detail. I particularly emphasise the issue of sun protection as I believe tanned skin or sun exposure too soon after treatment are the greatest causes of long-term complications. 

What product or device do you use and what is the treatment protocol?

RS: There is no one product or device that treats pigmentation. It is wise to use a stepwise pathway starting with the simplest and safest treatments first, as the more aggressive you become, the greater the risk of undesirable complications. For example some freckles respond well to the Alma Harmony AFT and other types of deeper pigmentation respond better to the Harmony i Pixel. For me, the Alma Harmony ClearLift Q-Switched is proving to be an effective treatment for pigment in darker skins types, at the same time producing skin tightening without side effects.
MG: I use the Q switched Nd:Yag system. For solar lentigines I am often able to completely treat individual lesions with one treatment, but I usually review patients at four weeks to see if a second treatment is required. If patients have a number of lesions and other features of photodamage I often carry out a full-face laser peel. My settings of choice for this treatment are 532nm wavelength and 6mm spot size at fluences of 0 .8 -1.2 J/cm2 .
SR: Treatment protocol depends on the underlying cause. Once medical causes have been excluded, sun protection is the most important consideration followed by topical preparations containing retinoids and sometimes hydroquinone (HQ) under close supervision. Some over the counter (OTC) products are useful in mild pigmentation problems. Treatment with chemical peels or Q switched Nd:Yag laser and fractionated CO2 lasers is the next step in the ladder.
HL: Every patient in my clinic is evaluated by me, then has a treatment plan to see how they respond to topical exfoliating, lightening and rebuilding agents over two to four weeks. Then we use fractional radiofrequency and Advanced Fluorescence Technology (AFT) treatments, which use short wave light. Lasers may never be necessary. I have 32 lasers and light devices in my practice. My preference is to use a 1064nm picosecond laser.

When would you use IPL over lasers?

RS: Intense pulsed light (IPL) and lasers can both be used. In my experience lasers are safer in some instances, such as for darker skin types, and IPL can be easier to cover larger areas. In my opinion IPL is not safe, and should be avoided, for Fitzpatrick photo types 5 & 6. Alma Harmony ClearLift Q-Switched Nd Yag laser generates less heat in darker skin types thereby minimising the risk of side effects in this skin type.

How do you diagnose type and depth of pigmentation in the dermis, and how does that affect treatment? 

Before and after HarmonyXL. Courtesy of Fernando Stengel,  M.D., Dermatologist, Buenos Aires, Argentina 

RS: A Woods light (ultra violet) can help to distinguish between purely epidermal (superficial) pigment and dermal (deep) pigment. However, it doesn’t tell you if there is a combination of both superficial and deep pigment, as is often the case in melasma.
LS: The stretch test is quick and easy as a first line of diagnosis. Pull the skin apart gently, if the pigment disappears it is epidermal, if it remains then it is dermal. Epidermal is much easier to treat. If the pigment is in the epidermis, it is often PIH, for which I use skincare, and lasers. Dermal pigmentation is caused by sun damage and hormones.
SR: We can judge the depth of pigmentation by its colour as it depends on the light reflection from the pigmentation. It is light brown when in the lower part of the epidermis/superficial dermis and gets a bluish tinge as it gets deeper in the dermis. Recurrence risk is higher for treating deeper pigmentation than superficial pigmentation.

What treatments can you use in conjunction with a laser treatment?

RS: I use topical pigment inhibitors such as kojic acid, arbutin, idebenone, tretinoin and also HQ, which is safe when used properly. Cryotherapy for localised lesions and chemical peeling are useful too.
MG: Q-switched lasers provide the best possibility for improvement in most conditions I treat, so I do not find it necessary to combine the treatments with other procedures such as chemical peels or other devices.

What is the role of skincare to prepare skin for treatment?

Obagi ZO range by Dr Obagi

RS: It is helpful to switch off the melanin production pathway by using topical pigment inhibitors for one or two months before treatment and also after treatment. Sunscreen is essential.
SR: I treat using strict skincare with topical retinoids for four weeks and insist on sun avoidance for four weeks before the laser treatment. Some OTC products by EU regulations have low permeable concentrations of synthetic vitamin A related compounds or HQ, kojic acid, gigawhite or glycolic acid, or thioglycolic acid, lactic acid, vitamin C, salicylic acid, niacinamide, beta arbutin, liquorice extracts, alpha tocopherol or chamomile extracts in different combinations. The alternatives are topical retinoids and HQ containing products on prescription.
MG: I combine treatments with anti-ageing creams especially to treat other features of photodamage. All my patients are required to use SPF 50+ sun protection for the duration of the treatment and afterwards.
LS: I believe that key to best treatment is pre-treatment skin conditioning. Healthy skin always responds better to laser therapies. Before treatment I recommend a six-week programme of skin conditioning using the ZO range by Dr Obagi. This is one complete skin cycle. For Asian skins and for patients with a lot of melanin, I will suggest treating through three skin cycles, or 18 weeks. I never offer laser treatment alone to patients with pigment problems.

Ochronosis is a growing issue. How do you treat it?

LS: Unfortunately in severe cases there is nothing you can do. But in many cases you can use a retinol-based product first, then use an HQ product, then add peels and laser. I had a patient who used HQ for four years. I put her on retinol for eight-nine months then used baby doses of HQ and did peels and got a great result.
SR: For ochronosis, sun avoidance and avoidance of creams containing HQ would be my first recommendation. It is difficult to treat, but a Q switched alexandrite laser, CO2 laser or TCA peels could be used. 

How do you treat melasma?

RS: Lasers and IPL are unpredictable for melasma as the heat from the treatment can stimulate more pigmentation and lead to a worsening of the condition.
SR: Sun avoidance, topical preparations and then laser or chemical peels would be good.
MG: I combine treatments with tyrosinase inhibitors such as HQ 4% cream.
LS: Melasma is the number one pigment-related complaint I see, and is one of the hardest pigmentation conditions to treat. It takes a lot of patient commitment and a lot of time. When treating melasma with Revlite I do a minimum of six treatments at two-week intervals, which I find gives good results. However, in older patients with very thin skin and melasma, it can be impossible to remove the pigment, though you can improve general skin health. It is vital to proceed gently. Aggressive laser treatment can trigger melanin or even cause hypopigmentation. I use less power and more treatments.

How do you approach treating UV triggered pigment?

LS: I am seeing increasing numbers of patients for sun damage, as they are now of an age to see the effects of sun exposure before the availability of high factor sunscreen. I suggest pre-conditioning, a doctor led chemical peel to resurface and repair damaged DNA, then I use laser to mop up any residual pigment. For freckles I simply do spot treatments using Revlite.
SR: For the sun damage and associated pigmentation, fractionated laser resurfacing is best as it also helps to iron out and reduce wrinkles together with pigmentation.

How can hypo and hyperpigmentation be avoided?

RS: Lasers and IPL can definitely lead to hypo and hyperpigmentation. Hypopigmentation is mostly seen after ablative laser treatments, especially the CO2 laser, and is permanent. More commonly we see PIH after non-ablative laser, such as in hair removal. This is not usually permanent but can be problematic, and is usually due to the heat from the laser or IPL. Warning signs are darker skin types, especially Fitzpatrick 4-6, and those whose skin shows increased pigmentation as a result of minor trauma such as cuts and scratches, or tendency to pigment after inflammatory conditions of the skin such as acne and eczema. Careful test patches with lower fluences and avoidance of too much erythema are important but do not mean it definitely will not occur.
MG: I advise the usual precautions of avoiding treating patients 
with a tan (whether real or fake) as this definitely increases the risk of hyperpigmentation in all skin types. Of course caution must be exercised in all patients with pigmented skin because of their higher risk of pigmentation, and I only use the Q-switched 1064nm laser in these patients. The most important aspect of treating all patients is correctly identifying their skin types. Those with intermediate skin types, Fitzpatrick type 3/4, can be quite challenging as results can be unimpressive with the 1064nm wavelength if the correct protocols are not used. Resist the temptation to try the 532nm without careful patch testing, and even then things can go wrong when wider areas are treated. 
SR: Lasers, chemical peels and creams containing HQ can cause hyper or hypopigmentation as a side effect. That is why it is important to evaluate each patient thoroughly for the possible underlying cause of hyperpigmentation before treatment.
HL: Too many doctors try to treat the problem too aggressively and too quickly. If pigmentation is made worse, then treating it gets more and more difficult. If using a laser I treat a single square centimeter and then monitor it for two to four weeks before treating the entire area. I have found that if you treat with lasers first, the chance of hypo or hyperpigmentation is at least 50%. 

Before and after treatment with Alex TriVantage laser 

What were your key considerations when choosing a laser?

RS: Courthouse Clinics chose Alma Harmony because of its multi platform technology that allows us to choose the correct type of laser or IPL for the individual patient. It’s a very versatile system that offers all forms of laser and light technology from one platform.
LS: I like Revlite by Cynosure. This is a Q switch laser, Nd:Yag 1060nm with a high melanin absorption rate. It shatters the pigment, which is then taken away by the lymphatic system. Revlite uses a photo acoustic pulse so I do not need additional cooling for pain relief.
MG: When I chose my Q-switched Nd:Yag system, I wanted a laser which had been around for a long time and had been used widely in countries where pigmentary problems dominate. Countries from which I sought feedback from my peers included Singapore, Hong Kong and Japan. I had a lot of good feedback about the Revlite and Trivantage systems.

What kind of follow-up do you offer patients post- treatments?

LS: It is vital to counsel patients to stay out of the sun during and after treatment. I recommend they use a thumbnail size amount of SPF50 on their face every day. I love Heliocare sunscreen. I never do a laser treatment without also offering a melanin control product, whether that contains a HQ or retinol.

What advice would you offer other practitioners when treating pigmentation, and when choosing a device/ treatment programme?

HL: The majority of catastrophes I inherit in my clinic are from doctors who use lasers and lights as the first approach to treating pigmentation. In my opinion it should never be more than a second line defence, after skincare and other modalities. My sincere advice is that if you don’t do this every day, then refer to someone who does. SR: Assess carefully, counsel thoroughly and use single treatment modalities at a time. Proper selection of treatment and realistic expectations are very important.
MG: Ensure you are able to identify the cause of pigmentation, for example post-inflammatory or sun damage, as this dictates the protocol to be used. For patients in whom post inflammatory pigmentation is the main issue, treatment for the underlying problem should be offered either before starting treatment or during the course of treatment. 

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