Treatment of melasma with mixed parameters of 1,064-nm Q-switched Nd:YAG laser toning and an enhanced effect of ultrasonic application of vitamin C: a split-face study

Melasma is an acquired pigment disorder showing symmetrical hyperpigmentation of the face characterized by light to dark brown patches with indistinct borders on both cheeks. Melasma is prevalent in middle-aged women with harmless hormone imbalances. It is also known as the mask of pregnancy and is prevalent in most child-bearing women. It fluctuates month by month, and yet, there is no promising treatment. The Q-switched neodymium-doped yttrium aluminum garnet (QS-Nd:YAG) laser (1,064-nm wavelength) was introduced in Asia years ago for both skin toning and treatment of facial pigment. This low-fluence, 1,064-nm QS-Nd: YAG laser also reportedly improved melasma. Adjunctive treatments such as vitamin C iontophoresis or chemical peels were recommended in other reports. The technique using the 1,064-nm QS-Nd:YAG laser for toning and the enhancement of adjunctive treatments need further investigation and long-term follow-up before recommendations for the ideal protocol for melasma treatment can be made. The aim of this study is to evaluate the improvement of melasma using different parameters with the 1,064-nm QS-Nd:YAG laser with ultrasonic application of topical vitamin C. Eight patients, ranging in age from 32 to 45 years (mean 37 years), with long-term melasma were studied. Most of the melasma cases were dermal or mixed-type melasma. The patients had no cosmetic treatment (laser, intense pulsed light, or chemical peel) 1 year prior to the study. The entire face of each patient was treated with the 1,064-nm QS-Nd:YAG laser for four sessions at 1-month intervals. The laser treatment was divided into three parts with different parameters. First, each patient underwent whole face exposure for one pass with an 8-mm spot size at a power of 2.0 J/cm(2). Next, the spot size was shifted to 6 mm at a power of 3.5 J/cm(2) for one full-face pass, and then ended with a 4-mm spot size at 3.2 J/cm(2) for one full-face pass, with multiple passes for the main lesions. The end point was mild erythema and swelling, without petechiae. All patients applied ice packs for 5 min before the adjunctive treatment. We designed a split-face study with or without ultrasonic application of topical vitamin C. Only the right side of the face received ultrasonic melasma application of vitamin C for 15 min after ice packing. The left side of the face was covered with a moisturizing lotion. Objective evaluation was performed with visual analog score. All eight patients completed the 3-month follow-up after the four laser treatments. Statistics showed significant improvement with ultrasonic application of vitamin C compared to laser monotherapy. The improvement was more pronounced during second to fourth sessions. There was no rebound or post-inflammatory hyperpigmentation detected during the 3-month follow-up period. The combination of 1,064-nm QS-Nd:YAG laser treatment with ultrasonic application of topical vitamin C exerted more prompt response of melasma. We recommended this protocol including mixed parameters of 1,064-nm QS-Nd:YAG laser toning method combining with vitamin C ultrasonic application that can yield higher satisfaction for the difficult facial pigmentation problems such as melasma.