JULY 2009 • WWW.SKINANDALLERGYNEWS.COM AESTHETIC DERMATOLOGY 21 Classify Melasma and Vitiligo Before Treatment BY AMY PFEIFFER Melasma that has an epidermal com- available in Ayurvedic and ponent will respond well to almost any other commercial prepara- S ANTA M ONICA, CALIF. — The treatment. Dermal melasma tends to re- tions. key to treating pigmentary disorders is spond better to laser therapies. Darker- Chemical peels are not ef- making an accurate diagnosis using a skinned patients will respond best to hy- fective as single agents for Wood’s lamp and classifying the pa- droquinone, while lighter skin responds treating melasma but may tient’s condition, according to Dr. Anand best to peels and lasers. be slightly synergistic when Ganesan. Patients with melasma need to use a used with hydroquinone. “One of the things that is easy to learn broad-spectrum sunscreen (UVA and Peels are operator depen- but is easily forgotten is how to really dent, said Dr. Ganesan, so if prepare your patients when they first ‘If you can the clinician has extensive walk in the door, and for you to assess categorize your clinical experience with how well they are going to respond to patients, you can them they may be a treat- OBERTS the treatments that you are offering,” actually predict ment option. E. R said Dr. Ganesan, who is a professor of very nicely how Studies suggest that the dermatology at the University of Cali- well they are Q-switched Nd:YAG and ENDY . W fornia, Irvine. going to respond.’ ruby lasers, used in con- R D Dr. Ganesan discussed the etiology, junction with hydroquinone, diagnosis, and treatment of pigmentary DR. GANESAN may be effective in treating OURTESY disorders, as well as the triaging of pa- dermal or mixed melasma. C tients with these conditions, at a cos- UVB coverage with an SPF of 30 or Positive results also have Possible melasma triggers include sun exposure, metic dermatology seminar sponsored more) every day, regardless of sun expo- been seen with Fraxel lasers. phenytoin exposure, and oral contraceptives. by Skin Disease Education Foundation sure, because fluorescent lighting emits (SDEF). some UVA rays, said Dr. Ganesan. Vitiligo sively with dose escalation for best treat- Birth control pills, cosmetic products, The underlying factor thought to cause ment results, Dr. Ganesan said. Because Melasma and phototoxic drugs should be discon- vitiligo is melanocyte susceptibility to de- aggressive dosing regimens can lead to About 75% of melasma patients are fe- tinued if they appear to help cause the struction. increased burning, it is best for treating male, and the condition is common in melasma. As with melasma, the diagnosis should localized areas and for patients who seek darker-skinned patients, he said. The ex- Combining topical products is more be made with a Wood’s lamp, which can rapid improvement. act cause of melasma is unknown, but effective than using tretinoin, hydro- distinguish vitiligo from other hypopig- Although the excimer laser should be triggers may include sun exposure, fam- quinone, or steroids alone, he said, menting conditions. Biopsy, along with avoided when treating underarms, the ily history, phenytoin exposure, oral adding that it is important to balance an Fontana-Masson staining, can be helpful device works well on the eyelids, he con- contraceptives, pregnancy, and in- agent’s potential for irritation with its to determine if melanocytes are pre- tinued. It produces less response on the creased estrogen. strength because increased inflamma- sent, Dr. Ganesan said. hands and feet but is an option if narrow- The Wood’s lamp is used to deter- tion will result in poor clinical out- There are two types of vitiligo: seg- band UVB has failed. mine the classification of melasma: epi- comes. mental (unresponsive to light therapy) Surgical options for treating vitiligo in- dermal, dermal, or mixed. “If you can For patients who cannot tolerate hy- and generalized (responsive to light ther- clude punch grafting and suction blister categorize your patients, you can actu- droquinone, there are some less effec- apy). Treatment options include photo grafting. Punch grafting has been found ally predict very nicely how well they tive alternatives: kojic acid, which can be therapy, lasers, surgery, and topical solu- very effective for treating nonactive seg- are going to respond to your treat- more irritating than hydroquinone; aze- tions. Given the safety and tolerability of mental lesions. A side effect of punch ment,” he said. laic acid; mequinol, which has been narrow-band UVB, it is favored over grafting is cobblestoning, which can di- In white and Hispanic patients, melas- shown to have some depigmenting ac- treatment with PUVA. minish over time. ma appears as a reflected darker image. In tivity and is less effective than hydro- A 380-nm excimer laser can be used to Dr. Ganesan disclosed having no con- patients with skin types V or VI the col- quinone; arbutin, which is a botanical- treat small surface areas, such as those on flicts related to his presentation. or will appear a little reddish, but a change ly related compound that can cause the face, but is less effective on the hands. SDEF and this news organization are can be seen over the pigmented area. depigmentation; and licorice extract, An excimer laser should be used aggres- both owned by Elsevier. ■ Lasers, Intense Pulsed Light Ease Pigmentation Disorders BY AMY PFEIFFER treat isolated vessels. When IPL treatment entered the it, which you can’t do with the IPL,” said Dr. Ross. “It’s scene, it displaced the other devices because of its ver- just fun to do.” The handpiece is also light and easy S ANTA M ONICA, CALIF. — The ideal device for satility, but all three approaches have a role in treating to use. treating pigmentation disorders would reduce wrinkles, blood and pigment lesions. “My favorite on a daily ba- KTP therapy has higher costs, however, and tends to pigment, and redness in one pass with a low amount sis is the KTP laser,” he acknowledged. cause more pain than IPL treatment. After KTP treat- of pain and give patients a fast, PDL treatment is fast, and if a ment, edema can be severe, and overtreatment can easy recovery, according to Dr. E. patient doesn’t mind the result- cause pitting. Victor Ross. My favorite laser ing purpura, the PDL is probably IPL therapy is raising the bar for treating pigmenta- “There’s no device that does all on a daily basis the best device for improvement tion. Filtration is better with an IPL device, lamp those things, but the devices that for treating of redness in a single treatment, pumping is smoother, cooling has been added to the de- actually selectively target blood pigmentation said Dr. Ross. vice, and the radio frequency has been improved. Most and melanin are possibly the clos- disorders is the The PDL remains the stan- importantly, it is safe, he said. est thing to it,” Dr. Ross said at a KTP. dard for treating port wine One of IPL’s drawbacks is that the divergence of the cosmetic dermatology seminar stains. Nevertheless, it is not pos- beam means the handpiece must be held close to the sponsored by Skin Disease Edu- DR. ROSS sible to reduce both red and skin, which may compress vessels. Also, the nonlaser cation Foundation (SDEF). brown facial lesions with this properties of IPL make it difficult to focus on small Dr. Ross of the Scripps Clinic in San Diego discussed laser, and it cannot, in one pass, treat both blood and spots, so it can be challenging to use on discrete lesions. the pros and cons of using intense pulsed light (IPL) pigment lesions. Finally, with large spot treatment capability comes the devices, pulsed dye lasers (PDL), and potassium-ti- KTP lasers can treat both small and large spots. The potential for big side effects, Dr. Ross noted. tanyl-phosphate (KTP) lasers for treating pigmentation spot-size reduction allows for safer treatment of darker- He disclosed being a consultant for, and receiving re- disorders. skinned (skin types IV and V) patients with telangiectasias. search grants from, Palomar. Dr. Ross also has received Both pigmentation and vascular disorders can be In addition, the device has a good vascular-to-pigment research support from Cutera Inc., Lumenis, Candela treated in one pass using IPL therapy and KTP lasers, damage ratio. When a 1- to 5-mm spot size is used, ves- Corp., Ulthera Inc., and Sciton Inc. he said. The PDL was the first “boutique laser” to treat sel reduction can be seen in real time. SDEF and this news organization are both owned by vascular lesions, he noted. Next came the KTP laser to “It is nice to see a blood vessel disappear as you see Elsevier. ■.