Goals, indications, contraindications
- To minimize melanin containing lesions
- Treatment can involve either removal of only the pigment or ablation of the entire lesion via ablative lasers.
- Melanin has a broad absorption spectrum; many lasers can be used to treat these lesions with appropriate laser selection considering the depth of the lesion.
- Ephelides and lentigines
- Superficial papillary dermis
- Best treated with IPL, BBL, 532 nm or QS 532 nm
- Ablative CO2 and erbium nicely remove, yet risk of recurrence
- Benign melanocytic nevi
- Controversial without pathology
- Post‑treatment fibroplasia overlying lesion can mask early signs of malignant change.
- Café au lait macules (CALM)
- Hypermelanosis of basal melanocytes and keratinocytes
- Prone to resistance and recurrence.
- Common yet complex and challenging condition with pigment in epidermal melanocytes and/or dermal melanophages caused by genetics, hormones, and UV light
- Commonly seen on the face in women after pregnancy or oral contraceptive use
- Recurrence is likely.
- PIH after treatment can exacerbate the problem.
- Treatment must be done in conjunction with topical retinoids, steroids, skin lightening creams, and sun block.
- Categorized by pigment depth and location
- Epidermal versus dermal pigment
- Woods lamp detects epidermal pigment.
- Dermal pigment does not respond to topical treatments.
- All the aforementioned lasers have been used; additionally, nonablative fractionated devices may of benefit, possibly by increasing drug delivery of hydroquinone through microthermal zones.
- Nevus of Ota
- Spindled melanocytes in papillary dermis; Nevus of Ota and blue nevi have similar histology.
- High fluences and multiple treatments spaced 6 weeks or more apart required
- Q‑switched lasers required; risk of hypopigmentation is lower with alexandrite.
- Postinflammatory hyperpigmentation (PIH)
- Can be due to melanin, extravasated hemosiderin after sclerotherapy, or drug metabolites.
- Topical treatment as described above.
- Q‑switched lasers expedite resolution.
- Relative: Fitzpatrick skin types 3–6 more prone to PIH and recurrence or unwanted hypopigmentation; a test spot can be used to determine patient individual response to treatment.
- Absolute: Pigmented intradermal melanocytic nevi require biopsy.
Long-pulsed devices with pigment chromophore
- Used at their shorter pulse widths (PW) available
- IPL or BBL: 500–1200 nm, 5–10 ms, ≤ 30 J/cm2, for lentigines and ephlids, nevi
- 532 nm KTP: 8–10 ms for superficial lentigines and ephlids
- 595 nm pulsed dye: 0.45–1.5 ms, 3–5 J/cm2, often used for treatment of vascular lesions, use of compression blanches the vascular component and allows melanin to be targeted
- 694 nm ruby: 1–4 ms, 5–30 J/cm2, acquired junctional melanocytic nevi, recurrence is common with congenital nevi due to remaining deeper nevus cells
- 755 nm alexandrite: 0.5–300 nm, acquired junctional melanocytic nevi, recurrence is common with congenital nevi due to remaining deeper nevus cells
- 800 nm diode: 5–100 ms, 5–50 J/cm2
- 1064 nm Neodymium:YAG: 1–100 ms, ≤ 300 J/cm2, nevi
Q‑switched lasers PW available in nanoseconds
- 532 nm frequency doubled Nd:YAG: 5–10 ms, 0.4–6 J/cm2, for superficial lentigines and ephlids
- 694 nm ruby: 20–40 ms, 3–12 J/cm2, good for deep pigment, nevus of Ota
- 755 nm alexandrite: 50–100 ms, 1–12 J/cm2, deep pigment, nevus of Ota
- 1064 nm Nd:YAG: 5–10 ms, 3–12 J/cm2, deeper penetration, useful for dermal pigmented lesions, safer than shorter wavelength lasers in darker skin
- Chromophore is water and not melanin
- 10,600 nm carbon dioxide: ablates lesion and surrounding epithelium with moderate coagulation, could risk PIH post‑o
- 2940 nm erbium YAG: ablates with minimal coagulation, slightly less risk of PIH
- History of skin cancer, autoimmune disease, resistant melasma
- Location of lesions
- Association with pregnancy or oral contraceptives
- Sun exposure/protection habits
- Best treated lesions are superficial ephelides and lentigines (lentigos).
- The physician needs to be confident in diagnosing
- Pigmented intradermal melanocytic nevi that contain a chaotic pigment pattern at risk for melanoma
- Hyperpigmented actinic keratosis
- Pigmented seborrheic keratosis
- Other potentially malignant lesions
- Patients must return for assessment if the laser treated lesion changes in the future.
- Medical aestheticians should not treat lesions unsupervised by the physician directly.
- Ability of an aesthetician to use IPL and BBL is determined by individual states laws.
- Both increase penetration of skin-lightening agents and lighten the skin themselves
- Decrease c‑Jun gene
- Increase TGF beta and matrix metalloproteinase
- OTC: Retinol, retinaldehyde
- Rx: tretinoin, tazarotene, adapalene
- Skin lighteners — block production of tyrosinase or block melanin transfer to keratinocyte
- Decapaptide 12 (Lumixyl)
- Kojic acid
- Elagic acid
- Hydroxyphenoxypropionic acid
- Bleach: lignin peroxidase (Elure)
- Fibroblast stabilization: yeast extract
- SPF: zinc, titanium
- Oral polypodium leucotomos extract (Heliocare)
- Multiple chemical peels
- Viable option possibly with less risk of PIH
- See chemical peel article: Salicylic acid (noninflammatory), TCA, glycolic
- Protective lenses worn by staff and patient because these devices can cause ocular damage
- Laser measures
- Sign on door
- Consider smoke evacuator.
- Skin might require open-wound healing, necessitating cleansing with vinegar soaks and emollients especially for ablative lasers. See above.
Patient management: treatment and follow‑up
If there is epithelial breakdown, consider vinegar soaks (1 cup water to 1 teaspoon distilled white vinegar) followed by emollient.
See topical medications in previous section.
Other management considerations
Patients should be aware that pigmented lesions could remain the same, improve, or less likely become more hyperpigmented, therefore diligent postoperative treatments described in the previous section should be followed for up to 6 months.
Should aestheticians be unsupervised in treating pigmented lesions when cancer is a risk?
- Failure to improve
- PIH (nonresolution or possibly increased pigment)
- Inadvertent hypopigmentation
The device treatments have not changed much over the past 20 years to treat pigmented lesions other than the development of the nonablative fractional devices. There has been much research and advancement in the area of topical skin lighteners that can be used in conjunction with device treatments.