Lasers Lighting the Way for Enhanced Treatment of Melasma and Tattoo Removal

On the surface, it would seem as though the skin condition melasma (commonly referred to as the “mask of pregnancy”) and tattoos would have little in common. However, they both affect a person’s skin, can be quite difficult to treat or remove and, now, dermatologists are discovering new laser therapies which enhance treatment for both conditions.

“Dermatologists are now finding that new laser therapies can significantly improve melasma and even remove tattoos more safely and effectively than laser procedures we have used in the past,” said dermatologist Arielle N.B. Kauvar, MD, FAAD, clinical professor of dermatology at New York University School of Medicine in New York City.

Combination Laser Therapy Targets Melasma
Melasma is caused by an overproduction of melanin, a natural substance in the body that gives skin its color and can lead to dark patches on the face. While melasma may occur in anyone, the condition most commonly affects women with darker Mediterranean skin, Asians and Hispanics. Dr. Kauvar explained that melasma is typically controlled with topical medications that contain ingredients to lighten the skin, such as hydroquinone or retinoids. Along with regular use of broad-spectrum sunscreen with a Sun Protection Factor (SPF) of 30 or higher, this treatment can resolve the excess pigmentation and prevent further darkening of the skin.

However, this therapy may only provide temporary improvement in more difficult cases– particularly in patients with mixed-type melasma. In this type of melasma, excess pigment is produced in both the epidermis and dermis – the upper and lower levels of the skin. While high-energy lasers for pigment removal and laser resurfacing have been investigated to treat this type of melasma, Dr. Kauvar explained that the procedures were too harsh and could wound the skin, leading to increased pigment production and worsening of melasma. More recently, fractional lasers – which are less aggressive lasers – have been used, but there have been reports of an increased incidence of melasma recurring as well.

“Effective treatment of mixed-type melasma requires a very low-energy and low-impact procedure because irritation and inflammation can worsen melasma,” said Dr. Kauvar. “Based on these requirements, I combined microdermabrasion, low-energy laser and a pigment-suppressing skin care regimen, which has shown to be painless, non-invasive, safe on any skin type and requires no downtime.”

Melasma is a common acquired hypermelanosis that occurs exclusively in sun-exposed areas; it is exacerbated by sun exposure, pregnancy, oral contraceptives, and certain antiepilepsy drugs. The most common presentation is a centrofacial pattern involving the cheeks, forehead, upper lip, nose, and chin. It may also involve the hands and arms. The type of hypermelanosis may be epidermal (brown), dermal (blue-gray), or mixed (brown-gray). Wood’s lamp examination distinguishes epidermal from dermal hyperpigmentation in all but skin phototypes V and VI, in which the Wood’s lamp is of no value. In skin phototypes I-IV, epidermal melasma is accentuated but dermal melasma is not.

Successful treatment of melasma involves the triad of sun blocks, bleach, and time. Without daily use of sunscreens, treatment will fail. Sunscreens should be opaque, broad-spectrum formulations with an SPF of at least 30. Bleaching preparations include 2% or 4% hydroquinone-containing creams or gels. Combination products containing sunscreens and hydroquinone are now available and are very effective and convenient for the patient. These are applied once daily. Simultaneous use of topical tretinoin gel (0.025%) is usually required as well.


It is commonly believed that dermal melasma is more difficult to treat, but there is no controlled, large study that proves this is true. The best approach is to begin treatment and adjust dosages and agents used based on response.

Amy J. McMichael, MD

With the new combination therapy, the dermatologist performs a microdermabrasion immediately followed by a low-energy laser treatment with a Q-switched YAG laser. Patients then begin a topical regimen using hydroquinone and sunscreen.

In Dr. Kauvar’s study of 27 women with mixed-type melasma, 22 subjects (81 percent) experienced greater than 75 percent improvement of their melasma after an average of 2.6 laser treatments. Of those, 11 subjects (40 percent) achieved over 95 percent improvement of their melasma. In addition, she found that clearance of melasma was maintained for at least six months.

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