Combining Low Power Fractional CO₂ With QS‐NdYAG Toning in the Treatment of Melasma Reduces the Incidence of Punctate Leukoderma

Abstract

Background and Objectives Q‐switched Nd:YAG (QS‐Nd:YAG) toning (low fluence, large spot size, and high frequency) has been used successfully for the treatment of melasma, especially in dark skin phototypes. Punctate leukoderma was found to be a frequent complication that reduced the safety of this procedure. Combining low power fractional CO2 laser, which is another effective melasma laser therapy, might improve the efficacy and safety of this procedure. The aim of this study was to evaluate the effect of combining low power fractional CO2 laser with QS‐Nd:YAG toning in the treatment of melasma. Study Design/Materials and Methods A randomized comparative split‐face study included a total of 30 patients with bilateral, symmetrical melasma. All patients received QS‐Nd:YAG toning on one randomly selected side of the face, while the other side randomly received either low power fractional CO2 alone (group A) or combined QS‐Nd:YAG toning with low power fractional CO2 (group B). QS‐Nd:YAG toning sessions were scheduled every two weeks for nine consecutive sessions, and low power fractional CO2 sessions were received every 4 weeks for three consecutive sessions. The assessment was done using the modified melasma area and severity index (mMASI) score, spectrophotometry (melanin index [MI] and erythema index [EI]), photography, blinded physician assessment, and patient satisfaction (at baseline, 1 week and 8‐12 weeks after the last treatment sessions). Results A significant reduction in the mMASI score and MI was obtained with all treatment regimens. On comparing different modalities, group A reduction in mMASI and MI was significantly greater on the side receiving QS‐ND:YAG toning (64.03% and 8.27%, respectively), than the side receiving low power fractional CO2 laser alone (36.02%. 2.64%, respectively). On the other hand, reduction of mMASI score and MI showed no statistical significance between the side receiving QS‐Nd:YAG toning alone and the combined modality. Punctate leukoderma occurred in four cases (13%) on the side receiving QS‐Nd:YAG toning. Conclusion QS‐Nd:YAG toning is significantly more effective than low power fractional CO2 in the treatment of melasma when used separately. Although combining low power fractional CO2 with QS‐Nd:YAG toning does not increase its efficacy, it minimizes the incidence of the undesirable punctate leukoderma complication and achieves lower recurrence. This combination can thus be recommended as a safe and effective measure for the treatment of melasma. © 2021 Wiley Periodicals LLC.

Treatment of melasma with a low‐fluence 1064 nm Q‐switched Nd:YAG laser: Laser toning in Caucasian women

“…The combined method did not increase efficacy but minimize the adverse reaction of punctate leukoderma and recurrence. 33 In our study, only a few patients experienced transient adverse events, including erythema and dryness. Only five out of 40 patients showed an insignificant increase in EI immediately after the first treatment but without serious complications during or after the final laser treatment.…”

The Low-Fluence Q-Switched Nd:YAG Laser Treatment for Melasma: A Systematic Review

“…The combination therapy of LFQSNY and other energy-based devices (EBD) showed better or similar efficacy with fewer adverse events compared to monotherapy [ 15 , 19 , 20 , 22 , 25 , 30 , 38 ]. Compared to LFQSNY alone, LFQSNY combined with fractional CO2 laser did not show a significant difference in outcome measures such as mMASI score, MI/EI score ( p > 0.05).…”

“…However, the risk of MH was lower in combination therapy compared to monotherapy. [ 15 ] The combination therapy of LFQSNY and fractional Er:YAG laser (FEYL) showed significantly higher improvement in Visioface ® scores and MI/EI scores than monotherapy. No serious adverse events were reported in both groups.…”

“…Despite the combination of LFQSNY with fractional CO 2 laser, FEYL, FMR, PDL (only in patients with visible vasodilatation on dermoscopy), LPNY, IPL, GA peeling, topical azelaic acid, or oral TXA showed significantly superior efficacy to LFQSNY alone, whereas FEGL and modified Jessner’s solution peel did not. However, it is notable that adverse events, such as MH and RH, were generally reduced in combination therapy (FEGL, FMR, LPNY, modified Jessner’s peeling) compared to LFQSNY alone [ 15 , 19 , 20 , 23 , 30 ]. Since melasma has a heterogeneous pathology as mentioned earlier, pigment-nonspecific treatment which targets the dermal pathology of melasma may exert synergistic effects by ameliorating the dermal environment.…”

“…Dev T. et al and Wattanakrai et al described that melasma recurred in all their patients who were followed up for 3 months [18,49], whereas Hofbauer et al and Zhou et al mentioned 81% and 64% recurrence rates, respectively [28,43]. However, contrarily, many other authors have reported significant improvement at 3 months after treatment [15,17,39,41,44].…”